Shared Decision Making

A Systematic Quality Assessment of Online Resources on Eyelid Ptosis Using the Modified Ensuring Quality Information for Patients (mEQIP) Tool

BACKGROUND

Eyelid ptosis is an underestimated pathology deeply affecting patients' quality of life. Internet has increasingly become the major source of information regarding health care, and patients often browse on websites to acquire an initial knowledge on the subject. However, there is lack of data concerning the quality of available information focusing on the eyelid ptosis and its treatment. We systematically evaluated online information quality on eyelid ptosis by using the "Ensuring Quality Information for Patients" (EQIP) scale.

MATERIALS AND METHODS

Google, Yahoo and Bing have been searched for the keywords "Eyelid ptosis," "Eyelid ptosis surgery" and "Blepharoptosis." The first 50 hits were included, evaluating the quality of information with the expanded EQIP tool. Websites in English and intended for general non-medical public use were included. Irrelevant documents, videos, pictures, blogs and articles with no access were excluded.

RESULTS

Out of 138 eligible websites, 79 (57,7%) addressed more than 20 EQIP items, with an overall median score of 20,2. Only 2% discussed procedure complication rates. The majority fail to disclose severe complications and quantifying risks, fewer than 18% clarified the potential need for additional treatments. Surgical procedure details were lacking, and there was insufficient information about pre-/postoperative precautions for patients. Currently, online quality information has not improved since COVID-19 pandemic.

CONCLUSIONS

This study highlights the urgent requirement for improved patient-oriented websites adhering to international standards for plastic and oculoplastic surgery. Healthcare providers should effectively guide their patients in finding trustworthy and reliable eyelid ptosis correction information.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial

Importance

Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians.

Objective

To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation.

Design, Setting, and Participants

This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022.

Intervention

The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care.

Main Outcome and Measures

The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing.

Results

A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase.

Conclusions and Relevance

In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool.

Trial Registration

ClinicalTrials.gov Identifier: NCT04857060.

The future of food allergy: Challenging existing paradigms of clinical practice

The field of food allergy has seen tremendous change over the past 5-10 years with seminal studies redefining our approach to prevention and management and novel testing modalities in the horizon. Early introduction of allergenic foods is now recommended, challenging the previous paradigm of restrictive avoidance. The management of food allergy has shifted from a passive avoidance approach to active interventions that aim to provide protection from accidental exposures, decrease allergic reaction severity and improve the quality of life of food-allergic patients and their families. Additionally, novel diagnostic tools are making their way into clinical practice with the goal to reduce the need for food challenges and assist physicians in the-often complex-diagnostic process. With all the new developments and available choices for diagnosis, prevention and therapy, shared decision-making has become a key part of medical consultation, enabling patients to make the right choice for them, based on their values and preferences. Communication with patients has also become more complex over time, as patients are seeking advice online and through social media, but the information found online may be outdated, incorrect, or lacking in context. The role of the allergist has evolved to embrace all the above exciting developments and provide patients with the optimal care that fits their needs. In this review, we discuss recent developments as well as the evolution of the field of food allergy in the next decade.

When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review

OBJECTIVE

To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC.

DATA SOURCES

Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically.

STUDY ELIGIBILITY CRITERIA

Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery.

RESULTS

Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC.

CONCLUSION

No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC.

PROSPERO REGISTRATION NUMBER

CRD42022155121.

'My doctor should decide' - Predictors for healthcare users' stated preferences regarding medical decision-making

OBJECTIVES

To investigate predictors for healthcare users' declared decision control preferences and test their association with satisfaction in vignettes detailing various decision-making.

METHODS

Cross-sectional vignette survey within a representative general male population aged 45-70 years (response rate 30%). Survey vignettes illustrated different levels of patient involvement. Participants rated their satisfaction with healthcare illustrated and separately rated their 'control preferences'. Comparisons were conducted with linear regression.

RESULTS

Preferring the doctor to predominantly or exclusively decide (1588/6755 respondents) was associated with older age, being single, lower education, having chronic illness, and living in low-income and less populated areas, with fewer non-western immigrants. Following adjustment, lower education and chronic illness remained statistically significant. Personalities with less openness had preference for least control. When presented with specific clinical scenarios, respondents preferring active or passive roles were equally satisfied with scenarios demonstrating shared decision-making.

DISCUSSION

Some groups of healthcare users were more likely to say that they preferred their doctor to decide. However, findings suggest that control preference statements, prior to facing a decision, should be interpreted with caution.

PRACTICAL VALUE

Study findings highlight that patients vary regarding their expressed wish for control in medical decision-making but they seem equally satisfied with shared decision-making scenarios.

American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation

ABSTRACT

Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.

For which decisions is Shared Decision Making considered appropriate? - A systematic review

OBJECTIVE

To identify decision characteristics for which SDM authors deem SDM appropriate or not, and what arguments are used.

METHODS

We applied two search strategies: we included SDM models from an earlier review (strategy 1) and conducted a new search in eight databases to include papers other than describing an SDM model, such as original research, opinion papers and reviews (strategy 2).

RESULTS

From the 92 included papers, we identified 18 decision characteristics for which authors deemed SDM appropriate, including preference-sensitive, equipoise and decisions where patient commitment is needed in implementing the decision. SDM authors indicated limits to SDM, especially when there are immediate life-saving measures needed. We identified four decision characteristics on which authors of different papers disagreed on whether or not SDM is appropriate.

CONCLUSION

The findings of this review show the broad range of decision characteristics for which authors deem SDM appropriate, the ambiguity of some, and potential limits of SDM.

PRACTICE IMPLICATIONS

The findings can stimulate clinicians to (re)consider pursuing SDM in situations in which they did not before. Additionally, it can inform SDM campaigns and educational programs as it shows for which decision situations SDM might be more or less challenging to practice.

Practices and perspectives of patients and healthcare professionals on shared decision-making in nephrology

Background

Given the complexity and variety in treatment options for advanced chronic kidney disease (CKD), shared decision-making (SDM) can be a challenge. SDM is needed for making decisions that best suit patients’ needs and their medical and living situations. SDM might be experienced differently by different stakeholders. This study aimed to explore clinical practice and perspectives on SDM in nephrology from three angles: observers, patients and healthcare professionals (HCPs).

Methods

An explanatory sequential mixed methods design was used. First, in the quantitative part of the study, outpatient consultations with patients with advanced chronic kidney disease (eGFR < 20 ml/min) were video recorded and SDM was assessed using the OPTION⁵ instrument. Subsequently, in the qualitative part, patients and HCPs reflected on their own SDM behaviour during individual stimulated recall interviews which were analysed using deductive thematic content analysis.

Results

Twenty nine consultations were recorded and observed in seven hospitals. The mean SDM score was 51 (range 25–80), indicating that SDM was applied to a moderate extent. The stimulated recall interviews with patients showed that they rely on the information provision and opinion of HCPs, expect consistency and support, and desire a proactive role. They also expect to be questioned by the HCP about their SDM preferences. HCPs said they were willing to incorporate patients’ preferences in SDM, as long as there are no medical contraindications. They also prefer patients to take a prominent role in SDM. HCPs ascribe various roles to themselves in supporting patients’ decision-making.

Conclusions

Although SDM was applied by HCPs to a moderate extent, improvement is needed, especially in helping patients get the information they need and in making sure that every patient is involved in SDM. This is even more important given the complex nature of the disease and the relatively high prevalence of limited health literacy among patients with chronic kidney disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02887-4.

Patient-centered outcomes for gastrointestinal cancer care: a scoping review protocol

INTRODUCTION

Following a cancer diagnosis, patients and their caregivers face crucial decisions regarding goals of care and treatment, which have consequences that can persist throughout their cancer journey. To foster informed and value-driven treatment choices, evidence-based information on outcomes relevant to patients is needed. Traditionally, clinical studies have largely focused on a few concrete and easily measurable outcomes such as survival, disease progression and immediate treatment toxicities. These outcomes do not capture other important factors that patients consider when making treatment decisions. Patient-centred outcomes (PCOs) reflect the patients' individual values, preferences, needs and circumstances that are essential to directing meaningful and informed healthcare discussions. Often, however, these outcomes are not included in research protocols in a standardised and practical fashion. This scoping review will summarise the existing literature on PCOs in gastrointestinal (GI) cancer care as well as the tools used to assess these outcomes. A comprehensive list of these PCOs will be generated for future efforts to develop a core outcome set.

METHODS AND ANALYSIS

This scoping review will follow Arksey and O'Malley's expanded framework for scoping reviews. We will systematically search Medline, Embase, CINAHL, Cochrane Library and APA PsycINFO databases for studies examining PCOs in the context of GI cancer. We will include studies published in or after the year 2000 up to the date of the final searches, with no language restrictions. Studies involving adult patients with GI cancers and discussion of any PCOs will be included. Opinion pieces, protocols, case reports and abstracts will be excluded. Two authors will independently perform two rounds of screening to select studies for inclusion. The data from full texts will be extracted, charted and summarised both quantitatively and qualitatively.

ETHICS AND DISSEMINATION

No ethics approval is required for this scoping review. Results will be disseminated through scientific publication and presentation at relevant conferences.

Does greater patient involvement in healthcare decision-making affect malpractice complaints? A large case vignette survey

Background

Although research findings consistently find poor communication about medical procedures to be a key predictor of patient complaints, compensation claims, and malpractice lawsuits (“complaints”), there is insufficient evidence to determine if greater patient involvement could actually affect the inclination to complain.

Objectives

We conducted an experimental case vignette survey that explores whether greater patient involvement in decision-making is likely to influence the intention to complain given different decisions and consequences.

Methods

Randomized, national case vignette survey with various levels of patient involvement, decisions, and outcomes in a representative Danish sample of men. We used prostate specific antigen (PSA) screening in men aged 45 to 70 years as the intervention illustrated in 30 different versions of a mock clinical encounter. Versions differed in the amount of patient involvement, the decision made (PSA test or no PSA test), and the clinical outcomes (no cancer detected, detection of treatable cancer, and detection of non-treatable cancer). We measured respondents’ inclination to complain about care in response to the scenarios on a 5-point Likert scale (from 1: very unlikely to 5: very likely).

Results

The response rate was 30% (6,756 of 22,288). Across all scenarios, the likelihood of complaint increased if the clinical outcome was poor (untreatable cancer). Compared with scenarios that involved shared decision-making (SDM), neutral information, or nudging in favor of screening, the urge to complain increased if the patient was excluded from decision-making or if the doctor had nudged the patient to decline screening (mean Likert differences .12 to .16, p < .001). With neutral involvement or nudging in favor of intervention, the desire to complain depended highly on the decision reached and on the patient’s course. This dependence was smaller with SDM.

Conclusions

Greater patient involvement in decision-making appears to be associated with less intention to complain about health care, with SDM resulting in the greatest reduction in complaint likelihood.

The use of implicit persuasion in decision-making about treatment for end-stage kidney disease

BACKGROUND

There are various options for managing end-stage kidney disease. Each option impacts the lives of patients differently. When weighing the pros and cons of the different options, patients' values, needs and preferences should, therefore, be taken into account. However, despite the best intentions, nephrologists may, more or less deliberately, convey a treatment preference and thereby steer the decision-making process. Being aware of such implicit persuasion could help to further optimise shared decision-making (SDM). This study explores verbal acts of implicit persuasion during outpatient consultations scheduled to make a final treatment decision. These consultations mark the end of a multi-consultation, educational process and summarise treatment aspects discussed previously.

METHODS

Observations of video-recorded outpatient consultations in nephrology (n = 20) were used to capture different forms of implicit persuasion. To this purpose, a coding scheme was developed.

RESULTS

In nearly every consultation nephrologists used some form of implicit persuasion. Frequently observed behaviours included selectively presenting treatment options, benefits and harms, and giving the impression that undergoing or foregoing treatment is unusual. The extent to which nephrologists used these behaviours differed.

CONCLUSION

The use of implicit persuasion while discussing different kidney replacement modalities appears diverse and quite common. Nephrologists should be made aware of these behaviours as implicit persuasion might prevent patients to become knowledgeable in each treatment option, thereby affecting SDM and causing decisional regret. The developed coding scheme for observing implicit persuasion elicits useful and clinically relevant examples which could be used when providing feedback to nephrologists.

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options

BACKGROUND

Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions.

QUESTIONS/PURPOSES

We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort.

METHODS

We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort.

RESULTS

There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001).

CONCLUSION

The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.

Is greater patient involvement associated with higher satisfaction? Experimental evidence from a vignette survey

BACKGROUND

Patient-centredness is an essential quality parameter of modern healthcare. Accordingly, involving patients in decisions about care is required by international laws and an increasing number of medical codes and standards. These directives are based on ethical principles of autonomy. Still, there is limited empirical knowledge about the influence of patient involvement on satisfaction with care.

OBJECTIVE

In a large national vignette survey, we aimed to empirically test healthcare users' satisfaction with healthcare given different degrees of patient involvement, choices made and outcomes.

METHODS

A web-based cross-sectional survey distributed to a randomised sample of men in Denmark aged 45-70 years. Case vignettes used prostate-specific antigen (PSA) screening for early detection of prostate cancer as a clinical model. Using a 5-point Likert scale, we measured respondents' satisfaction with care in scenarios which differed in the amount of patient involvement (ranging from no involvement, through involvement with neutral or nudged information, to shared decision-making), the decision made (PSA test or no PSA test) and clinical outcomes (no cancer detected, detection of treatable cancer and detection of non-treatable cancer).

RESULTS

Participating healthcare users tended to be more satisfied with healthcare in scenarios illustrating greater levels of patient involvement. Participants were positive towards nudging in favour of the intervention but patient involvement through shared decision-making obtained the highest satisfaction ratings (Likert rating 3.81 without any involvement vs 4.07 for shared decision-making, p<0.001). Greater involvement also had an ameliorating effect on satisfaction if a non-treatable cancer was later diagnosed.

CONCLUSION

Our study provides empirical support for the hypothesis that greater patient involvement in healthcare decision-making improves satisfaction with care irrespective of decisions made and clinical outcomes. Overall satisfaction with the care illustrated was highest when decisions were reached through shared decision-making.

How to approach shared decision making when determining consolidation, maintenance therapy, and transplantation in acute myeloid leukemia

Until recently, treatment options for patients with acute myeloid leukemia (AML) were limited to cytotoxic chemotherapeutic agents that possessed little specificity for the cytogenetic and molecular mutations known to risk stratify patients with this disease. With the approval of multiple new therapies, not only have the agents that we treat patients with changed, but the way we talk about these options, decide on, and manage therapy has also been transformed. Given these complexities, it is important that we help patients make an informed decision by weighing the risk of relapse with patient wishes and desired quality of life. Shared decision making (SDM) is an approach to medical decision making for those situations in which most clinicians would agree that there is more than 1 correct choice for a patient. Here we review the principles of SDM and provide an overview of the 3-talk model and how it may be incorporated into the care of patients with AML.

Developing and evaluating a patient decision aid for hormone therapy to manage symptoms of surgical menopause: the story behind the "SheEmpowers" patient decision aid

OBJECTIVES

To develop and evaluate an evidence-based patient decision aid (PDA) that can support women making decisions on hormone therapy (HT) for the management of early surgical menopause.

METHODS

The PDA development was guided by the Ottawa Decision Support Framework and the International Patient Decision Aid Standards and involved three phases: an exploratory phase to identify women's decisional needs; a development phase to identify evidence related to treatment options and draft initial prototype; and an evaluation phase to evaluate the prototype and elicit views on acceptability in women (N = 12). All phases were driven by a multidisciplinary group of researchers, clinicians, and patient stakeholders to ensure women's priorities were met.

RESULTS

A prototype PDA was drafted based on needs identified from the exploratory phase. The PDA has five domains: information on surgical menopause and HT; HT outcome probabilities; patient stories; values clarification; and guidance in deliberation. Participants in the evaluation phase perceived the tool as acceptable and offered suggestions for modifications.

CONCLUSION

Through our adopted, systematic approach the SheEmpowers PDA was developed to help women overcome deterrents to decision-making related to lack of knowledge, decision-making skills, and involvement in therapy decisions. The decisional effectiveness of the tool is to be assessed in future studies.

Shared decision-making in the care of a patient with food allergy

OBJECTIVE

Shared decision-making is a patient-centered approach that involves a mutual discussion about management or treatment options, which account for the patient's underlying values and preferences for therapy. Little is known about the role of shared decision-making in the care of patients with food allergy.

DATA SOURCES

A narrative review of the shared decision-making and food allergy outcomes literature in the past 20 years was performed.

RESULTS

In shared decision-making, care must be taken to help clarify the patient's values regarding their care options, but not instill the clinician's values or preferences into that choice. It is essential to understand the mutual roles of the clinician in the process of providing evidence-based options for care, advocating for treatments that are aligned with their goals and preferences, and allowing patients to make fully informed decisions within this paradigm. Decision support tools such as decision aids can assist patients in the values clarification process, particularly in which preference-sensitive care exists, in which options hold significant tradeoffs and varying outcomes, and the decision is reflective of personal values and preferences. There are multiple potential preference-sensitive care scenarios in food allergy in which shared decision-making could be optimized, including the development of decision aids. These areas include early allergenic solid introduction, preemptive epinephrine use in which there is allergen exposure but no symptoms, automatic activation of EMS after using epinephrine, and choices of food allergy treatment. Only one decision aid in food allergy exists.

CONCLUSION

Shared decision-making is an approach that could greatly enhance food allergy care and improve patient-reported outcomes.

Men's view on participation in decisions about prostate-specific antigen (PSA) screening: patient and public involvement in development of a survey

Background

Prostate-Specific Antigen (PSA) screening for early detection of prostate cancer (PCa) may prevent some cancer deaths, but also may miss some cancers or lead to unnecessary and potentially harmful treatment. Therefore, involving patients in decision-making about PSA screening is recommended. However, we know little about the attitude of men regarding participation in decisions about PSA screening and how to assess such attitudes. The purpose of this paper is to describe patient and public participation in the development of a national, web-based case vignette survey for studying men’s view on participation in decision-making about PSA screening.

Methods

The project group developed a first draft plan for the survey, its vignettes and choice of measurements. This included multiple vignette variants representing various levels of patient participation in decision-making about PSA screening with different outcomes. Additionally, it included questions on respondents’ satisfaction with imagined courses of health care, their propensity to initiate a malpractice complaint, their own health care experiences, socio-demography, personality, and preferences for control regarding health care decision-making. Following feedback from a workshop with academic peers on the draft plan, a group of 30 adult men was engaged to help develop case vignette versions and questionnaire items by providing feedback on structure, comprehension, response patterns, and time required to complete the survey. Furthermore, a panel of three patients with PCa experience was assembled to assist development through a separate review-and-feedback process.

Results

Based on reviews of survey drafts, the large group made further suggestions about construction of the survey (e.g. clarification and modification of case vignette versions, deletion of items and adjustment of wording, instructions to guide respondents, replacement of technical terms, and optimization of sequence of survey elements). The patient panel ensured fine-tuning of vignette versions and questionnaire items and helped review the internet version of the survey.

Conclusions

Patient and public involvement during various phases of the survey development helped modify and refine survey structure and content. The survey exemplifies a way to measure health care users’ satisfaction with imagined courses of health care and wish to complain, taking into account their characteristics.

COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic

In the event of a global infectious pandemic, drastic measures may be needed that limit or require adjustment of ambulatory allergy services. However, no rationale for how to prioritize service shut down and patient care exists. A consensus-based ad-hoc expert panel of allergy/immunology specialists from the United States and Canada developed a service and patient prioritization schematic to temporarily triage allergy/immunology services. Recommendations and feedback were developed iteratively, using an adapted modified Delphi methodology to achieve consensus. During the ongoing pandemic while social distancing is being encouraged, most allergy/immunology care could be postponed/delayed or handled through virtual care. With the exception of many patients with primary immunodeficiency, patients on venom immunotherapy, and patients with asthma of a certain severity, there is limited need for face-to-face visits under such conditions. These suggestions are intended to help provide a logical approach to quickly adjust service to mitigate risk to both medical staff and patients. Importantly, individual community circumstances may be unique and require contextual consideration. The decision to enact any of these measures rests with the judgment of each clinician and individual health care system. Pandemics are unanticipated, and enforced social distancing/quarantining is highly unusual. This expert panel consensus document offers a prioritization rational to help guide decision making when such situations arise and an allergist/immunologist is forced to reduce services or makes the decision on his or her own to do so.

An Ethical Claim for Providing Medical Recommendations in Pediatric Intensive Care

The Declaration of Geneva was recently revised to emphasize patient autonomy and the importance of clinicians sharing medical knowledge. This reflects the welcome evolution of the doctor-patient relationship from one of paternalism to more informed, shared decision-making. Unfortunately, there is an increasing trend for clinicians to avoid making recommendations, instead providing a "menu" of care options from which patients and families must choose. This seems to be underpinned by the belief that it is unacceptably paternalistic to give guidance as to which course of action may be best to take. In this article, we argue that there is an ethical imperative for doctors to provide medical recommendations. This is discussed with particular emphasis on the pediatric critical care setting, where autonomy and shared decision-making are especially complex. We outline how a failure to provide clinical recommendations represents inadequate shared decision-making and erodes the doctor-patient relationship, leading to suboptimal care, paradoxically decreasing respect for autonomy. We describe an approach through which doctors can avoid paternalism without placing an undue burden of decision-making on families. We assert that patients' interests are best served by clinicians taking an active, relational role in shared decision-making, including exploration of values and giving explicit medical recommendations for care.

Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology

While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur. Our objective was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients 1 week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36% recalled with a prompt; 15% recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and “teach back,” were rare. Patients with less than high school education recalled 38% of items freely and accurately, while patients with a college degree recalled 65% (p < .0001). In a multivariate model, the total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider (“verbal dominance”), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.

Training health professionals in shared decision making: Update of an international environmental scan

OBJECTIVE

To update an environmental scan of training programs in SDM for health professionals.

METHODS

We searched two systematic reviews for SDM training programs targeting health professionals produced from 2011 to 2015, and also in Google and social networks. With a standardized data extraction sheet, one reviewer extracted program characteristics. All completed extraction forms were validated by a second reviewer.

RESULTS

We found 94 new eligible programs in four new countries and two new languages, for a total of 148 programs produced from 1996 to 2015-an increase of 174% in four years. The largest percentage appeared since 2012 (45.27%). Of the 94 newprograms, 42.55% targeted licensed health professionals (n=40), 8.51% targeted pre-licensure (n=8), 28.72% targeted both (n=27), 20.21% did not specify (n=19), and 5.32% targeted also patients (n=5). Only 23.40% of the new programs were reported as evaluated, and 21.28% had published evaluations.

CONCLUSIONS

Production of SDM training programs is growing fast worldwide. Like the original scan, this update indicates that SDM training programs still vary widely. Most still focus on the single provider/patient dyad and few are evaluated.

PRACTICE IMPLICATIONS

This update highlights the need to adapt training programs to interprofessional practice and to evaluate them.

Use of Decision Aids with Minority Patients: a Systematic Review

BACKGROUND

One potential approach to reducing health disparities among minorities is through the promotion of shared decision making (SDM). The most commonly studied SDM intervention is the decision aid (DA). While DAs have been extensively studied, we know relatively little about their use in minority populations. We conducted a systematic review to characterize the application and effectiveness of DAs in racial, ethnic, sexual, and gender minorities.

METHODS

We searched PubMed for randomized controlled trials (RCTs) evaluating DAs between 2004 and 2013. We included trials that enrolled adults (> 18 years of age) with > 50 % representation by minority patients. Four reviewers independently assessed 597 initially identified articles, and those with inconclusive results were discussed to consensus. We abstracted decision quality, patient-doctor communication, and clinical treatment decision outcomes. Results were considered significantly modified by the DA if the study reported p < 0.05.

RESULTS

We reviewed 18 RCTs of DA interventions in minority populations. The majority of interventions (78 %) addressed cancer screening. The most common mode of delivery for the DAs was personal counseling (46 %), followed by multi-media (29 %), and print materials (25 %). Most of the trials studied racial (78 %) or ethnic (17 %) minorities with only one trial focused on sexual minorities and none on gender minorities. Ten studies tailored their interventions for their minority populations. Comparing intervention vs. control, decision quality outcomes improved in six out of eight studies and patient-doctor communication improved in six out of seven studies. Of the 15 studies that reported on clinical decisions, eight demonstrated significant changes in decisions with DAs.

DISCUSSION

DAs have been effective in improving patient-doctor communication and decision quality outcomes in minority populations and could help address health disparities. However, the existing literature is almost non-existent for sexual and gender minorities and has not included the full breadth of clinical decisions that affect minority populations.

Does a strategy to promote shared decision-making reduce medical practice variation in the choice of either single or double embryo transfer after in vitro fertilisation? A secondary analysis of a randomised controlled trial

OBJECTIVES

The hypothesis that shared decision-making (SDM) reduces medical practice variations is increasingly common, but no evidence is available. We aimed to elaborate further on this, and to perform a first exploratory analysis to examine this hypothesis. This analysis, based on a limited data set, examined how SDM is associated with variation in the choice of single embryo transfer (SET) or double embryo transfer (DET) after in vitro fertilisation (IVF). We examined variation between and within hospitals.

DESIGN

A secondary analysis of a randomised controlled trial.

SETTING

5 hospitals in the Netherlands.

PARTICIPANTS

222 couples (woman aged <40 years) on a waiting list for a first IVF cycle, who could choose between SET and DET (ie, ≥2 embryos available).

INTERVENTION

SDM via a multifaceted strategy aimed to empower couples in deciding how many embryos should be transferred. The strategy consisted of decision aid, support of IVF nurse and the offer of reimbursement for an extra treatment cycle. Control group received standard IVF care.

OUTCOME MEASURE

Difference in variation due to SDM in the choice of SET or DET, both between and within hospitals.

RESULTS

There was large variation in the choice of SET or DET between hospitals in the control group. Lower variation between hospitals was observed in the group with SDM. Within most hospitals, variation in the choice of SET or DET appeared to increase due to SDM. Variation particularly increased in hospitals where mainly DET was chosen in the control group.

CONCLUSIONS

Although based on a limited data set, our study gives a first insight that including patients' preferences through SDM results in less variation between hospitals, and indicates another pattern of variation within hospitals. Variation that results from patient preferences could be potentially named the informed patient rate. Our results provide the starting point for further research.

TRIAL REGISTRATION NUMBER

NCT00315029; Post-results.

Mental Health Nursing, Mechanical Restraint Measures and Patients' Legal Rights

Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients' legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients' rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient's mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients' rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.

Engaging stakeholders to develop a depression management decision support tool in a tribal health system

PURPOSE

Southcentral Foundation, an Alaska Native tribal health organization, has had a depression screening program in primary care since 2001. Program monitoring identified gaps in antidepressant refills and patients' follow-up with behavioral health services. With extensive stakeholder participation, we developed an electronic, patient-centered, depression-management decision support tool (DM-DST). Quality of life and other outcomes are being assessed in a separate study; this case study reports on the multi-year stakeholder engagement process.

METHODS

Data sources included interviews with patients and providers from integrated primary care teams, notes from research meetings, steering committee meetings, and consultations with tribal health system leadership, human subjects review committees, providers, and software designers, and a pilot test of the DS-DMT with patients and providers. We analyzed these sources using qualitative methods to assess the impact of stakeholder input on project processes and outcomes.

RESULTS

One comprehensive, iPad-based tool was originally planned to facilitate discussions about depression management. Stakeholder input emphasized the role of family and cultural context of depression and management and improving the usability of the DM-DST. Stakeholder direction led us to split the DM-DST into: (1) a brief iPad-based tool to facilitate conversations between patients and providers during clinic visits; and (2) a complementary Web site that provides detailed information and allows patients flexibility and time to learn more about depression and share information and preferences with family and friends.

CONCLUSIONS

Stakeholder input across the project substantially modified the DM-DST to ensure cultural applicability to patients and providers and facilitate integration into clinics.

An overview of patient involvement in healthcare decision-making: a situational analysis of the Malaysian context

BACKGROUND

Involving patients in decision-making is an important part of patient-centred care. Research has found a discrepancy between patients' desire to be involved and their actual involvement in healthcare decision-making. In Asia, there is a dearth of research in decision-making. Using Malaysia as an exemplar, this study aims to review the current research evidence, practices, policies, and laws with respect to patient engagement in shared decision-making (SDM) in Asia.

METHODS

In this study, we conducted a comprehensive literature review to collect information on healthcare decision-making in Malaysia. We also consulted medical education researchers, key opinion leaders, governmental organisations, and patient support groups to assess the extent to which patient involvement was incorporated into the medical curriculum, healthcare policies, and legislation.

RESULTS

There are very few studies on patient involvement in decision-making in Malaysia. Existing studies showed that doctors were aware of informed consent, but few practised SDM. There was limited teaching of SDM in undergraduate and postgraduate curricula and a lack of accurate and accessible health information for patients. In addition, peer support groups and 'expert patient' programmes were also lacking. Professional medical bodies endorsed patient involvement in decision-making, but there was no definitive implementation plan.

CONCLUSION

In summary, there appears to be little training or research on SDM in Malaysia. More research needs to be done in this area, including baseline information on the preferred and actual decision-making roles. The authors have provided a set of recommendations on how SDM can be effectively implemented in Malaysia.

Observations of evidence-based medicine in general practice

No objective measures are available for assessing the practice of evidence-based medicine (EBM) in general practitioner (GP) trainees, as there is no description of the EBM behaviour that is expected from trainees. As a first step to do so, we aimed to identify which expressions of EBM (defined as the integration of evidence, clinical experience and patient situation) can be observed in daily GP practice. Secondly, we aimed to identify which considerations GPs had regarding EBM but did not share with the patient during consultations. We performed a qualitative study, in which GPs were observed during and interviewed after clinical consultations, with a focus on expressions and considerations related to EBM during clinical decision-making. We observed 147 consultations by 34 GPs (17 trainers and 17 trainees). EBM behaviour was rarely visible in GPs' decision-making. When interviewing the GPs, we found that aspects of EBM that played a role in decision-making were not discussed with the patient. Explicit consideration of all aspects of EBM would make EBM measurable and GPs more aware of the foundations of their decisions. EBM behaviour is difficult to observe during GP consultations and therefore cannot be assessed through observations alone.

Shared decision-making in the selection of outpatient analgesics for older individuals in the emergency department

OBJECTIVES

To assess the relationship between older adults' perceptions of shared decision-making in the selection of an analgesic to take at home for acute musculoskeletal pain and (1) patient satisfaction with the analgesic and (2) changes in pain scores at 1 week.

DESIGN

Cross-sectional study.

SETTING

Single academic emergency department.

PARTICIPANTS

Individuals aged 65 and older with acute musculoskeletal pain.

MEASUREMENTS

Two components of shared decision-making were assessed: information provided to the patient about the medication choice and patient participation in the selection of the analgesic. Optimal satisfaction with the analgesic was defined as being "a lot" satisfied. Pain scores were assessed in the ED and at 1 week using a 0-to-10 scale.

RESULTS

Of 159 individuals reached by telephone, 111 met all eligibility criteria and completed the survey. Fifty-two percent of participants reported receiving information about pain medication options, and 31% reported participating in analgesic selection. Participants who received information were more likely to report optimal satisfaction with the pain medication than those who did not (67% vs 34%; P < .001). Participants who participated in the decision were also more likely to report optimal satisfaction with the analgesic (71% vs 43%; P = .008) and had a greater average decrease in pain score (4.1 vs 2.9; P = .05). After adjusting for measured confounders, participants who reported receiving information remained more likely to report optimal satisfaction with the analgesic (63% vs 38%; P = .04).

CONCLUSION

Shared decision-making in analgesic selection for older adults with acute musculoskeletal pain may improve outcomes.

The medium is the (health) measure: patient engagement using personal technologies

With the phrase "the medium is the message", Marshall McLuhan argued that technologies are the messages themselves and not just the medium. Almost 50 years later, we understand that modern information and communication technologies expand our ability to perceive our world to an extent that would be impossible without the medium. In this article, we contend that information and communication technologies are becoming the dominant medium for patient engagement. Information and communication technologies will efficiently change patient-reported measurement into much more behaviorally sophisticated information that will create a very different interaction between patients and a new kind of health care workforce.