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Elliott D, Ochieng CA, Zahra J, McNair AG, Main BG, Skilton A, Blencowe NS, Cousins S, Paramasivan S, Hoffmann C, Donovan JL, Blazeby JM. What Are Patients Told About Innovative Surgical Procedures? A Qualitative Synthesis of 7 Case Studies in the United Kingdom. Ann Surg 2023; 278:e482-e490. [PMID: 36177849 PMCID: PMC10414150 DOI: 10.1097/sla.0000000000005714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate how information about innovative surgical procedures is communicated to patients. BACKGROUND Despite the national and international guidance that patients should be informed whether a procedure is innovative and has uncertain outcomes, little is known about current practice. METHODS This qualitative study followed 7 "case studies" of surgical innovation in hospitals across the United Kingdom. Preoperative interviews were conducted with clinician innovators (n=9), preoperative real-time consultations between clinicians and patients were audio-recorded (n=37). Patients were interviewed postoperatively (n=30). Data were synthesized using thematic analytical methods. RESULTS Interviews with clinicians demonstrated strong intentions to inform patients about the innovative nature of the procedure in a neutral manner, although tensions between fully informing patients and not distressing them were raised. In the consultations, only a minority of clinicians actually made explicit statements about, (1) the procedure being innovative, (2) their limited clinical experience with it, (3) the paucity of evidence, and (4) uncertainty/unknown outcomes. Discussions about risks were generalized and often did not relate to the innovative component. Instead, all clinicians optimistically presented potential benefits and many disclosed their own positive beliefs. Postoperative patient interviews revealed that many believed that the procedure was more established than it was and were unaware of the unknown risks. CONCLUSIONS There were contradictions between clinicians' intentions to inform patients about the uncertain outcomes of innovative and their actual discussions with patients. There is a need for communication interventions and training to support clinicians to provide transparent data and shared decision-making for innovative procedures.
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Affiliation(s)
- Daisy Elliott
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Cynthia A. Ochieng
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jesmond Zahra
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Angus G.K. McNair
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, North Bristol NHS Trust, University of Bristol, Bristol, England
| | - Barry G. Main
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University Hospitals Bristol, Weston NHS Foundation Trust, University of Bristol, Bristol, England
| | - Anni Skilton
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Natalie S. Blencowe
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University Hospitals Bristol, Weston NHS Foundation Trust, University of Bristol, Bristol, England
| | - Sian Cousins
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Sangeetha Paramasivan
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Christin Hoffmann
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jenny L. Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jane M. Blazeby
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Papastefan ST, De Boer C, Zeineddin S, Hu A, Harris CJ, Wall JK, Hunter CJ, Lautz TB, Goldstein SD. Innovation versus Experimentation: An Application of Ethical Frameworks to the Acceptance of Fluorescence-Guided Pediatric Surgery. J Pediatr Surg 2023; 58:1609-1612. [PMID: 37330376 DOI: 10.1016/j.jpedsurg.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/26/2023] [Accepted: 05/14/2023] [Indexed: 06/19/2023]
Abstract
Innovation is essential to the advancement of the field of pediatric surgery. The natural skepticism toward new technologies in pediatrics leads to frequent confusion of surgical innovation and research. Using fluorescence-guided surgery as an archetype for this ethical discussion, we apply existing conceptual frameworks of surgical innovation to understand the distinction between innovation and experimentation, acknowledging the spectrum and "grey zone" in between. In this review, we discuss the role of Institutional Review Boards in evaluating surgical practice innovations, and the aspects of certain surgical innovations that are distinct from experimentation, including a thorough understanding of the risk profile, preexisting use in humans, and adaptation from related fields. Examining fluorescence-guided surgery through these existing frameworks as well as the concept of equipoise, we conclude that new applications of indocyanine green do not constitute human subjects research. Most importantly, this example gives practitioners a lens through which they may appraise potential surgical innovations to allow for a sensible and efficient improvement of the field of pediatric surgery. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Steven T Papastefan
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Christopher De Boer
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Suhail Zeineddin
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew Hu
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Courtney J Harris
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James K Wall
- Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Catherine J Hunter
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Timothy B Lautz
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Seth D Goldstein
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Surgical informed consent: new challenges. Curr Probl Surg 2023; 60:101258. [PMID: 36813352 DOI: 10.1016/j.cpsurg.2022.101258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
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Hoffmann C, Hossaini S, Cousins S, Blencowe N, McNair AGK, Blazeby JM, Avery KNL, Potter S, Macefield R. Reporting Modifications in Surgical Innovation: A Systematic Scoping Review Protocol. Int J Surg Protoc 2021; 25:250-256. [PMID: 34825118 PMCID: PMC8588892 DOI: 10.29337/ijsp.167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/07/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Innovation in surgery drives improvements to patient care. New surgical procedures and devices typically undergo a series of modifications as they are developed and refined during their introduction into clinical practice. These changes should ideally be reported and shared between surgeon-innovators to promote efficient, safe and transparent innovation. Currently, agreement on how modifications should be defined, conceptualised and classified, so they can be reported and shared efficiently and transparently, is lacking. The aim of this review is to examine and summarise existing literature on definitions, perceptions and classifications of modifications to surgical procedures/devices, including views on how to measure and report them. The findings will inform future work to standardise reporting and sharing of modifications in surgical innovation. MATERIALS AND METHODS A systematic scoping review will be conducted adhering to PRISMA-ScR guidelines. Included articles will focus on review articles and opinion pieces relevant to modifications to new surgical procedures or devices introduced to clinical practice. Methods to identify relevant literature will include systematic searches in MEDLINE (Ovid version), targeted internet searches (Google Scholar) and snowball searches. A two-stage screening process (titles/abstracts/keywords and full-texts) will use specified exclusion/inclusion criteria to identify eligible articles. Data on how modifications are i) defined, ii) perceived, and iii) classified, and iv) views on how modifications should be measured and reported, will be extracted verbatim. Inductive thematic analysis will be applied to extracted data where appropriate. Results will be presented as a narrative summary including descriptive characteristics of included articles. Findings will inform a preliminary conceptual framework to facilitate the systematic reporting and sharing of modifications to novel procedures and devices. HIGHLIGHTS This work will generate an in-depth understanding of how modifications are currently defined, perceived and classified, and views on how they may be reported, in the context of surgical innovation.Rigorous and comprehensive search methods will be applied to identify a wide range of diverse data sources for inclusion in the review.A summary of existing relevant literature on modifications is a necessary step to inform development of a framework for transparent, real-time reporting and sharing of modifications in future studies of innovative invasive procedures/devices.
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Affiliation(s)
- Christin Hoffmann
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sina Hossaini
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sian Cousins
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Natalie Blencowe
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Angus G. K. McNair
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Bristol, UK
| | - Jane M. Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kerry N. L. Avery
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Shelley Potter
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Bristol, UK
| | - Rhiannon Macefield
- National Institute for Health Research Bristol Biomedical Research Centre (Surgical Innovation Theme), Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
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