1
|
Abdul-Samed AB, Peprah EB, Jahan Y, Reichenberger V, Balabanova D, Mirzoev T, Lawson H, Odei E, Antwi E, Agyepong I. Exploring the path to optimal diabetes care by unravelling the contextual factors affecting access, utilisation, and quality of primary health care in West Africa: A scoping review protocol. PLoS One 2024; 19:e0294917. [PMID: 38768121 PMCID: PMC11104679 DOI: 10.1371/journal.pone.0294917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/13/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The prevalence of diabetes in West Africa is increasing, posing a major public health threat. An estimated 24 million Africans have diabetes, with rates in West Africa around 2-6% and projected to rise 129% by 2045 according to the WHO. Over 90% of cases are Type 2 diabetes (IDF, World Bank). As diabetes is ambulatory care sensitive, good primary care is crucial to reduce complications and mortality. However, research on factors influencing diabetes primary care access, utilisation and quality in West Africa remains limited despite growing disease burden. While research has emphasised diabetes prevalence and risk factors in West Africa, there remains limited evidence on contextual influences on primary care. This scoping review aims to address these evidence gaps. METHODS AND ANALYSIS Using the established methodology by Arksey and O'Malley, this scoping review will undergo six stages. The review will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR) guidelines to ensure methodological rigour. We will search four electronic databases and search through grey literature sources to thoroughly explore the topic. The identified articles will undergo thorough screening. We will collect data using a standardised data extraction form that covers study characteristics, population demographics, and study methods. The study will identify key themes and sub-themes related to primary healthcare access, utilisation, and quality. We will then analyse and summarise the data using a narrative synthesis approach. RESULTS The findings and conclusive report will be finished and sent to a peer-reviewed publication within six months. CONCLUSION This review protocol aims to systematically examine and assess the factors that impact the access, utilisation, and standard of primary healthcare services for diabetes in West Africa.
Collapse
Affiliation(s)
| | | | - Yasmin Jahan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Dina Balabanova
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tolib Mirzoev
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Henry Lawson
- Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Eric Odei
- Korle Bu Teaching Hospital, Accra, Ghana
| | | | | |
Collapse
|
2
|
Kimura M, Toyoda M, Saito N, Takahashi M, Isozumi K, Kato E, Kawanami D, Fukagawa M. The Importance of Patient and Family Engagement, the Needs for Self-Monitoring of Blood Glucose (SMBG) - Our Perspectives Learned Through a Story of SMBG Assistive Devices Made by a Husband of the Patient with Diabetes. Diabetes Metab Syndr Obes 2022; 15:1627-1638. [PMID: 35642182 PMCID: PMC9148577 DOI: 10.2147/dmso.s363762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Despite some negative reports regarding the need for the self-monitoring of blood glucose (SMBG), including the issue of cost-effectiveness, there are still many users, and in diabetes treatment, which is largely dependent on the patient's self-care, SMBG remains an important tool in establishing such self-care habits, with several reports supporting this notion. In addition, devices are needed to assist in SMBG for patients with diabetes who have difficulty performing SMBG, such as the elderly or those with visual impairment. In current diabetes care, it is reported that patient-centered care that respects the preferences, needs, and values of individual patients and personalized care that consider the characteristics and comorbidities of each patient are important. Through a case study of a patient with diabetes who had difficulty performing SMBG due to visual impairment, we learned of the needs of SMBG and its assistive devices and the importance of patient and family engagement with emphasis on patient-centered and personalized care. We herein report what we learned through this case in the form of perspectives. Through this report, we hope that medical professionals involved in diabetes care will learn of the importance and needs of these issues and apply them to their actual clinical practice.
Collapse
Affiliation(s)
- Moritsugu Kimura
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Correspondence: Moritsugu Kimura, Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan, Tel +81-463-93-1121 (ext. 2490), Fax +81-463-91-3350, Email
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Nobumichi Saito
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Makiko Takahashi
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Konomi Isozumi
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Eri Kato
- Seichi Clinic, Isehara, Kanagawa, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| |
Collapse
|
3
|
Halvorsrud K, Kucharska J, Adlington K, Rüdell K, Brown Hajdukova E, Nazroo J, Haarmans M, Rhodes J, Bhui K. Identifying evidence of effectiveness in the co-creation of research: a systematic review and meta-analysis of the international healthcare literature. J Public Health (Oxf) 2021; 43:197-208. [PMID: 31608396 PMCID: PMC8042368 DOI: 10.1093/pubmed/fdz126] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/03/2019] [Accepted: 09/17/2019] [Indexed: 12/15/2022] Open
Abstract
Background To investigate and address the evidence gap on the effectiveness of co-creation/production in international health research. Methods An initial systematic search of previous reviews published by 22 July 2017 in Medline, Embase, PsycINFO, Scopus and Web of Science. We extracted reported aims, elements and outcomes of co-creation/production from 50 reviews; however, reviews rarely tested effectiveness against intended outcomes. We therefore checked the reference lists in 13 included systematic reviews that cited quantitative studies involving the public/patients in the design and/or implementation of research projects to conduct meta-analyses on their effectiveness using standardized mean difference (SMD). Results Twenty-six primary studies were included, showing moderate positive effects for community functions (SMD = 0.56, 95%CI = 0.29–0.84, n = 11) and small positive effects for physical health (SMD = 0.25, 95%CI = 0.07–0.42, n = 9), health-promoting behaviour (SMD = 0.14, 95%CI = 0.03–0.26, n = 11), self-efficacy (SMD = 0.34, 95%CI = 0.01–0.67, n = 3) and health service access/receipt (SMD = 0.36, 95%CI = 0.21–0.52, n = 12). Non-academic stakeholders that co-created more than one research stage showed significantly favourable mental health outcomes. However, co-creation was rarely extended to later stages (evaluation/dissemination), with few studies specifically with ethnic minority groups. Conclusions The co-creation of research may improve several health-related outcomes and public health more broadly, but research is lacking on its longer term effects.
Collapse
Affiliation(s)
- Kristoffer Halvorsrud
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Justyna Kucharska
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.,Westminster University, 115 New Cavendich Street, London, W1W 6UW, UK
| | - Katherine Adlington
- East London NHS Foundation Trust, City and Hackney Centre for Mental Health, Homerton Row, London, E9 6SR, UK
| | - Katja Rüdell
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Eva Brown Hajdukova
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - James Nazroo
- Sociology, School of Social Sciences, University of Manchester, Humanities, Bridgeford Street, Oxford Road, Manchester, M13 9PL, UK
| | - Maria Haarmans
- Sociology, School of Social Sciences, University of Manchester, Humanities, Bridgeford Street, Oxford Road, Manchester, M13 9PL, UK
| | - James Rhodes
- Sociology, School of Social Sciences, University of Manchester, Humanities, Bridgeford Street, Oxford Road, Manchester, M13 9PL, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| |
Collapse
|
4
|
de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. Development of three different decision support tools to support shared decision-making in vascular surgery. PATIENT EDUCATION AND COUNSELING 2021; 104:282-289. [PMID: 33277102 DOI: 10.1016/j.pec.2020.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is known to improve quality of care. Particularly in vascular surgery treatment options are often preference-sensitive. Unfortunately, vascular surgeons infrequently apply SDM. Decision support tools (DSTs) have been shown to be helpful in SDM. OBJECTIVE This article describes the development process of three different DSTs to help vascular surgeons and patients apply SDM. PATIENT INVOLVEMENT Patients' information needs were obtained via focus group meetings. Fifty-two patients and eighteen vascular surgeons not involved in the development process evaluated the comprehensibility and usability of the DST-prototypes. METHODS A multidisciplinary steering group commissioned the development of the three DSTs according to international standards. RESULTS Digital decision aids and paper-based consultation cards and decision cards were developed for patients with an abdominal aortic aneurysm, carotid artery disease, intermittent claudication or varicose veins. Patients preferred the use of the decision aids followed by consultation cards, whereas vascular surgeons preferred to use decision cards followed by decision aids. DISCUSSION Decision aids, consultation cards and decision cards for four vascular diseases are now available to all vascular surgeons and patients in the Netherlands. The DSTs were well received by both surgeons and patients. English versions are also available.
Collapse
Affiliation(s)
- Sylvana M L de Mik
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Fabienne E Stubenrouch
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron Balm
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands.
| |
Collapse
|
5
|
Banasiak K, Hux J, Lavergne C, Luk J, Sohal P, Paty B. Facilitating barriers: Contextual factors and self-management of type 2 diabetes in urban settings. Health Place 2020; 61:102267. [PMID: 32329732 DOI: 10.1016/j.healthplace.2019.102267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 11/28/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
Urban environments create unique challenges for the management of type 2 diabetes (T2D). City living is associated with unhealthy occupational, nutritional, and physical activity patterns. However, it has also been linked to behaviours that promote health, such as walking and cycling for transportation. Our research is situated at the intersection of these contradictory findings. We ask: What aspects of urban living impact the ability of those living with diabetes to reach optimal health? What contextual and structural factors influence how barriers are experienced in the everyday lives of those living with T2D? We conducted semi-structured interviews with 29 individuals living in Toronto and Vancouver. Interviews were recorded, transcribed, and systematically coded for themes and sub-themes. In addition to affirming readily acknowledged barriers to diabetes management, such as accessing healthy, culturally appropriate food and the cost of management, our findings suggest that the unpredictable nature of urban living creates barriers to routinizing self-management practices. As large, cosmopolitan centres with an abundance of activities on offer, cities pulls people away from home, making adherence to self-management recommendations more difficult. Moreover, our findings challenge commonly held assumptions about the mutually exclusive and static nature of barriers and facilitators. Public transit, a readily acknowledged facilitator of healthy living, can be experienced as a barrier to diabetes management. Participants report intentional non-adherence to their medication regimens for fear of hypoglycemia in subway or traffic delays. While the stimulating nature of cities promotes walkability, it produces barriers as well: participants partake in more restaurant eating than they would if they lived in a rural area and were home to cook their own meals. Understanding how barriers are experienced by people living with diabetes will help mitigate some of the unintended consequences associated with various contextual factors. We recommend that healthcare professionals acknowledge and support people with T2D in routinizing self-management and developing contingency plans for the unpredictability and complexity that urban living entails. We suggest further research be carried out to develop contextually-tailored municipal policies and interventions that will support self-management and improve outcomes for individuals living with T2D in urban settings.
Collapse
|
6
|
Hargraves I. Beyond involvement: multiple methods and purposes of shared decision making. J Comp Eff Res 2019; 8:1345-1347. [PMID: 31789051 DOI: 10.2217/cer-2019-0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Ian Hargraves
- Knowledge & Evaluation Research Unit, Mayo Clinic, 200 First St SW Rochester, 55905-0002 MN, USA
| |
Collapse
|
7
|
Macalalad-Josue AA, Palileo-Villanueva LA, Sandoval MA, Panuda JP. Development of a Patient Decision Aid on the Choice of Diabetes Medication for Filipino Patients with Type 2 Diabetes Mellitus. J ASEAN Fed Endocr Soc 2019; 34:44-55. [PMID: 33442136 PMCID: PMC7784104 DOI: 10.15605/jafes.034.01.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/20/2018] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To develop a locally adapted patient decision aid (PtDA) on treatment intensification among Filipino patients with Type 2 Diabetes Mellitus and to test the feasibility of using PtDAs in a low middle-income country. METHODOLOGY A qualitative approach and an iterative process of development of a PtDA were employed for this study. We describe the process of developing a Filipino version of the Diabetes Medication Decision Aid. This PtDA was designed to help the patient choose the appropriate treatment intensification based on his own values and preferences, in consultation with his physician. The process involved decisional needs assessment through focus group discussions and key informant interviews, systematic literature review, iterative process of the development of a PtDA with clinical encounters (pilot testing), and preliminary field testing. RESULTS Decisional needs assessment revealed that Filipino patients are open to participate in shared decision-making if given the opportunity, including those with low socioeconomic status who likely have low health literacy. Physicians prefer to have visual aid tools to help them support their patient's decision-making. A PtDA prototype of a set of flash cards in Filipino was created and revised in an iterative method. We developed a more visually appealing tool after inputs from the expert panel and patient advisory group. Its use during clinical encounters provided additional insights from patients and clinicians on how to improve the PtDA. Preliminary field testing showed that its use is feasible in the target patient population. CONCLUSION Filipino patients, clinicians, and diabetes nurse educators have contributed to the creation of the first Filipino PtDA for diabetes treatment intensification.
Collapse
Affiliation(s)
- Anna Angelica Macalalad-Josue
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of the Philippines-Philippine General Hospital
| | | | - Mark Anthony Sandoval
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of the Philippines-Philippine General Hospital
| | - Jose Paolo Panuda
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of the Philippines-Philippine General Hospital
| |
Collapse
|
8
|
Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, Castaneda-Guarderas A, Gionfriddo MR, Branda ME, Montori VM. Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters. J Gen Intern Med 2019; 34:36-40. [PMID: 29968051 PMCID: PMC6318197 DOI: 10.1007/s11606-018-4540-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/18/2018] [Accepted: 06/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Eliciting patient concerns and listening carefully to them contributes to patient-centered care. Yet, clinicians often fail to elicit the patient's agenda and, when they do, they interrupt the patient's discourse. OBJECTIVE We aimed to describe the extent to which patients' concerns are elicited across different clinical settings and how shared decision-making tools impact agenda elicitation. DESIGN AND PARTICIPANTS We performed a secondary analysis of a random sample of 112 clinical encounters recorded during trials testing the efficacy of shared decision-making tools. MAIN MEASURES Two reviewers, working independently, characterized the elicitation of the patient agenda and the time to interruption or to complete statement; we analyzed the distribution of agenda elicitation according to setting and use of shared decision-making tools. KEY RESULTS Clinicians elicited the patient's agenda in 40 of 112 (36%) encounters. Agendas were elicited more often in primary care (30/61 encounters, 49%) than in specialty care (10/51 encounters, 20%); p = .058. Shared decision-making tools did not affect the likelihood of eliciting the patient's agenda (34 vs. 37% in encounters with and without these tools; p = .09). In 27 of the 40 (67%) encounters in which clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7-22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3-19; range 2 to 108 s) to state their concern. CONCLUSIONS Clinicians seldom elicit the patient's agenda; when they do, they interrupt patients sooner than previously reported. Physicians in specialty care elicited the patient's agenda less often compared to physicians in primary care. Failure to elicit the patient's agenda reduces the chance that clinicians will orient the priorities of a clinical encounter toward specific aspects that matter to each patient.
Collapse
Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Rochester, MN, USA
| | | | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Rochester, MN, USA
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Universidad Autónoma de Nuevo Leon, Monterrey, Mexico
- Laboratorio Nacional para el Estudio y Aplicación de la Medicina Basada en Evidencia, Análisis Crítico de la Información Científica y Farmacoeconomía, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | | | - Megan E Branda
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Rochester, MN, USA.
| |
Collapse
|
9
|
Deerochanawong C, Bajpai S, Dwipayana IMP, Hussein Z, Mabunay MA, Rosales R, Tsai ST, Tsang MW. Optimizing Glycemic Control Through Titration of Insulin Glargine 100 U/mL: A Review of Current and Future Approaches with a Focus on Asian Populations. Diabetes Ther 2017; 8:1197-1214. [PMID: 29094298 PMCID: PMC5688987 DOI: 10.1007/s13300-017-0322-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Indexed: 01/25/2023] Open
Abstract
Various data have demonstrated inadequate glycemic control amongst Asians with type 2 diabetes mellitus (T2DM), possibly on account of suboptimal titration of basal insulin-an issue which needs to be further examined. Here we review the available global and Asia-specific data on titration of basal insulin, with a focus on the use of insulin glargine 100 U/mL (Gla-100). We also discuss clinical evidence on the efficacy and safety of titrating Gla-100, different approaches to titration, including some of the latest technological advancements, and guidance on the titration of basal insulin from international and local Asian guidelines. The authors also provide their recommendations for the initiation and titration of basal insulin for Asian populations. Discussion of the data included in this review and in relation to the authors' clinical experience with treating T2DM in Asian patients is also included. Briefly, clinical studies demonstrate the achievement of adequate glycemic control in adults with T2DM through titration of Gla-100. However, studies investigating approaches to titration, specifically in Asian populations, are lacking and need to be conducted. Given that the management of insulin therapy is a multidisciplinary team effort involving endocrinologists, primary care physicians, nurse educators, and patients, greater resources and education targeted at these groups are needed regarding the optimal titration of basal insulin. Technological advancements in the form of mobile or web-based applications for automated dose adjustment can aid different stakeholders in optimizing the dose of basal insulin, enabling a larger number of patients in Asia to reach their target glycemic goals with improved outcomes.
Collapse
|
10
|
Brinkman WB, Lipstein EA, Taylor J, Schoettker PJ, Naylor K, Jones K, Vora SS, Mims CC, Roth-Wojcicki E, Gottlieb B, Griffin N, Lannon C, Morgan E. Design and implementation of a decision aid for juvenile idiopathic arthritis medication choices. Pediatr Rheumatol Online J 2017; 15:48. [PMID: 28583183 PMCID: PMC5460481 DOI: 10.1186/s12969-017-0177-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/30/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Randomized trials have demonstrated the efficacy of patient decision aids to facilitate shared decision making in clinical situations with multiple medically reasonable options for treatment. However, little is known about how best to implement these tools into routine clinical practice. In addition, reliable implementation of decision aids has been elusive and spread within pediatrics has been slow. We sought to develop and reliably implement a decision aid for treatment of children with juvenile idiopathic arthritis. METHODS To design our decision aid, we partnered with patient, parent, and clinician stakeholders from the Pediatric Rheumatology Care and Outcomes Improvement Network. Six sites volunteered to use quality improvement methods to implement the decision aid. Four of these sites collected parent surveys following visits to assess outcomes. Parents reported on clinician use of the decision aid and the amount of shared decision making and uncertainty they experienced. We used chi-square tests to compare eligible visits with and without use of the decision aid on the experience of shared decision making and uncertainty. RESULTS After 18 rounds of testing and revision, stakeholders approved the decision aid design for regular use. Qualitative feedback from end-users was positive. During the implementation project, the decision aid was used in 35% of visits where starting or switching medication was discussed. Clinicians used the decision aid as intended in 68% of these visits. The vast majority of parents reported high levels of shared decision making following visits with (64/76 = 84%) and without (80/95 = 84%) use of the decision aid (p = 1). Similarly, the vast majority of parents reported no uncertainty following visits with (74/76 = 97%) and without (91/95 = 96%) use of the decision aid (p = 0.58). CONCLUSIONS Although user acceptability of the decision aid was high, reliable implementation in routine clinical care proved challenging. Our parsimonious approach to outcome assessment failed to detect a difference between visits with and without use of our aid. Innovative approaches are needed to facilitate use of decision aids and the assessment of outcomes.
Collapse
Affiliation(s)
- William B. Brinkman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Ellen A. Lipstein
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Janalee Taylor
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Pamela J. Schoettker
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Katherine Naylor
- University of Cincinnati College of Design, Architecture, Art and Planning, 5470 Aronoff, Cincinnati, OH 45221 USA
| | - Karla Jones
- Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Sheetal S. Vora
- Levine Children’s Hospital, 1000 Blythe Blvd, Charlotte, NC 28203 USA
| | - Catherine C. Mims
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425 USA
| | | | - Beth Gottlieb
- Cohen Children’s Medical Center of New York, 269-1 76th Ave, Queens, NY 11040 USA
| | - Nancy Griffin
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Carole Lannon
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Esi Morgan
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| |
Collapse
|
11
|
Lauffenburger JC, Lewey J, Jan S, Nanchanatt G, Makanji S, Ferro CA, Sheehan J, Wittbrodt E, Morawski K, Lee J, Ghazinouri R, Choudhry NK. Rationale and design of the ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus (ENGAGE-DM) pragmatic trial. Contemp Clin Trials 2017; 59:57-63. [PMID: 28571997 DOI: 10.1016/j.cct.2017.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Poor glycemic control among patients with diabetes may stem from poor medication and lifestyle adherence or a failure to appropriately intensify therapy. A patient-centered approach could discern the most likely possibility and would then, as appropriate, address patient barriers to non-adherence (using behavioral interviewing methods such as motivational interviewing) or help facilitate choices among treatment augmentation options (using methods such as shared decision-making). OBJECTIVE To test the impact of a novel telephone-based patient-centered intervention on glycemic control for patients with poorly-controlled diabetes. METHODS/DESIGN ENGAGE-DM (ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus) is a pragmatic trial of patients with poorly-controlled diabetes receiving treatment with an oral hypoglycemic agent. We randomized 1400 patients in a large health insurer to intervention or usual care. The intervention is delivered over the telephone by a pharmacist and consists of a 2-step process that integrates brief negotiated interviewing and shared decision-making to identify patient-concordant goals and options for enhancing patients' diabetes management. The trial's primary outcome is disease control, assessed using glycosylated hemoglobin values. Secondary outcomes include medication adherence measures, assessed using pharmacy claims data. CONCLUSIONS This trial will determine whether a novel highly-scalable patient engagement strategy improves disease control and adherence to medications among individuals with poorly-controlled diabetes.
Collapse
Affiliation(s)
- Julie C Lauffenburger
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Saira Jan
- Horizon Blue Cross Blue Shield, NJ, USA; Rutgers State University of New Jersey, New Brunswick, NJ, USA
| | | | | | | | - John Sheehan
- AstraZeneca, US-Medical Affairs, Fort Washington, PA, USA
| | - Eric Wittbrodt
- AstraZeneca, US-Medical Affairs, Fort Washington, PA, USA
| | - Kyle Morawski
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jessica Lee
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Roya Ghazinouri
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
12
|
Hansen RA, Williamson M, Stevenson L, Davis BR, Evans RL. Disseminating Comparative Effectiveness Research Through Community-based Experiential Learning. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2017; 81:9. [PMID: 28289299 PMCID: PMC5339595 DOI: 10.5688/ajpe8119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/13/2015] [Indexed: 06/06/2023]
Abstract
Objectives. To launch and evaluate a comparative effectiveness research education and dissemination program as part of an introductory pharmacy practice experience (IPPE). Methods. First- through third-year PharmD students received training on comparative effectiveness research and disseminated printed educational materials to patients in the community who they were monitoring longitudinally (n=314). Students completed an assessment and initial visit documentation form at the first visit, and a follow-up assessment and documentation form at a subsequent visit. Results. Twenty-three diabetes patients, 29 acid-reflux patients, 30 osteoarthritis patients, and 50 hypertension patients received materials. Aside from the patient asking questions, which was the most common outcome (n=44), the program resulted in 38 additional actions, which included stopping, starting, or changing treatments or health behaviors, or having additional follow-up or diagnostic testing. Small but positive improvements in patient understanding, confidence, and self-efficacy were observed. Conclusions. Dissemination of comparative effectiveness research materials in an IPPE program demonstrated a positive trend in markers of informed decision-making.
Collapse
Affiliation(s)
| | | | - Lynn Stevenson
- Auburn University, Harrison School of Pharmacy, Auburn, Alabama
| | - Brandy R Davis
- Auburn University, Harrison School of Pharmacy, Auburn, Alabama
| | - R Lee Evans
- Auburn University, Harrison School of Pharmacy, Auburn, Alabama
| |
Collapse
|
13
|
Rodriguez-Gutierrez R, Gionfriddo MR, Ospina NS, Maraka S, Tamhane S, Montori VM, Brito JP. Shared decision making in endocrinology: present and future directions. Lancet Diabetes Endocrinol 2016; 4:706-716. [PMID: 26915314 DOI: 10.1016/s2213-8587(15)00468-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/05/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023]
Abstract
In medicine and endocrinology, there are few clinical circumstances in which clinicians can accurately predict what is best for their patients. As a result, patients and clinicians frequently have to make decisions about which there is uncertainty. Uncertainty results from limitations in the research evidence, unclear patient preferences, or an inability to predict how treatments will fit into patients' daily lives. The work that patients and clinicians do together to address the patient's situation and engage in a deliberative dialogue about reasonable treatment options is often called shared decision making. Decision aids are evidence-based tools that facilitate this process. Shared decision making is a patient-centred approach in which clinicians share information about the benefits, harms, and burden of different reasonable diagnostic and treatment options, and patients explain what matters to them in view of their particular values, preferences, and personal context. Beyond the ethical argument in support of this approach, decision aids have been shown to improve patients' knowledge about the available options, accuracy of risk estimates, and decisional comfort. Decision aids also promote patient participation in the decision-making process. Despite accumulating evidence from clinical trials, policy support, and expert recommendations in endocrinology practice guidelines, shared decision making is still not routinely implemented in endocrine practice. Additional work is needed to enrich the number of available tools and to implement them in practice workflows. Also, although the evidence from randomised controlled trials favours the use of this shared decision making in other settings, populations, and illnesses, the effect of this approach has been studied in a few endocrine disorders. Future pragmatic trials are needed to explore the effect and feasibility of shared decision making implementation into routine endocrinology and primary care practice. With the available evidence, however, endocrinologists can now start to practice shared decision making, partner with their patients, and use their expertise to formulate treatment plans that reflect patient preferences and are more likely to fit into the context of patients' lives. In this Personal View, we describe shared decision making, the evidence behind the approach, and why and how both endocrinologists and their patients could benefit from this approach.
Collapse
Affiliation(s)
- Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, University Hospital "Dr. Jose E. Gonzalez", Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - Michael R Gionfriddo
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Graduate School, Mayo Clinic, Rochester, MN, USA
| | - Naykky Singh Ospina
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Spyridoula Maraka
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shrikant Tamhane
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
14
|
Goh SY, Ang E, Bajpai S, Deerochanawong C, Hong EG, Hussein Z, Joshi S, Kamaruddin NA, Kho S, Kong APS, Pan CY, Perfetti R, Vichayanrat A, Vlajnic A, Chan JCN. A patient-centric approach to optimise insulin therapy in Asia. J Diabetes Complications 2016; 30:973-80. [PMID: 27288201 DOI: 10.1016/j.jdiacomp.2016.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/20/2016] [Accepted: 05/20/2016] [Indexed: 11/16/2022]
Affiliation(s)
| | - Ernesto Ang
- Cardinal Santos Medical Center, San Juan, Philippines; The Institute for Studies on Diabetes Foundation Inc., Metro Manila, Philippines
| | | | | | - Eun-Gyoung Hong
- Hallym University School of Medicine, Dongtan Sacred Heart Hospital, Gyeonggi-do, South Korea
| | | | | | | | - Sjoberg Kho
- University of Santo Tomas, Manila, Philippines
| | | | | | | | | | | | | |
Collapse
|
15
|
Nicklett EJ, Omidpanah A, Whitener R, Howard BV, Manson SM. Access to Care and Diabetes Management Among Older American Indians With Type 2 Diabetes. J Aging Health 2016; 29:206-221. [PMID: 26944805 DOI: 10.1177/0898264316635562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine the relationship between health care access and diabetes management among a geographically diverse sample of American Indians (AIs) aged 50 and older with type 2 diabetes. METHOD We examined the relationship between access to care and diabetes management, as measured by HbA1c, using 1998-1999 data from the Strong Heart Family Study. A series of bivariate and multivariate linear models examined the relationships between nine access-related variables and HbA1c levels. RESULTS In bivariate analyses, out-of-pocket costs were associated with higher HbA1c levels. No other access-related characteristics were significantly associated with diabetes management in bivariate or in multivariate models. DISCUSSION Access-related barriers were not associated with worse diabetes management in multivariate analyses. The study concludes with implications for clinicians working with AI populations to enhance opportunities for diabetes management.
Collapse
Affiliation(s)
- Emily J Nicklett
- 1 University of Michigan School of Social Work, Ann Arbor, MI, USA
| | - Adam Omidpanah
- 2 Washington State University College of Nursing, Spokane, WA, USA
| | - Ron Whitener
- 3 University of Washington School of Law, Seattle, WA, USA
| | - Barbara V Howard
- 4 MedStar Health Research Institute; Hyattsville, MD, USA; Georgetown University School of Medicine, Washington, D.C., USA
| | - Spero M Manson
- 5 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
16
|
Badgeley MA, Shameer K, Glicksberg BS, Tomlinson MS, Levin MA, McCormick PJ, Kasarskis A, Reich DL, Dudley JT. EHDViz: clinical dashboard development using open-source technologies. BMJ Open 2016; 6:e010579. [PMID: 27013597 PMCID: PMC4809078 DOI: 10.1136/bmjopen-2015-010579] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To design, develop and prototype clinical dashboards to integrate high-frequency health and wellness data streams using interactive and real-time data visualisation and analytics modalities. MATERIALS AND METHODS We developed a clinical dashboard development framework called electronic healthcare data visualization (EHDViz) toolkit for generating web-based, real-time clinical dashboards for visualising heterogeneous biomedical, healthcare and wellness data. The EHDViz is an extensible toolkit that uses R packages for data management, normalisation and producing high-quality visualisations over the web using R/Shiny web server architecture. We have developed use cases to illustrate utility of EHDViz in different scenarios of clinical and wellness setting as a visualisation aid for improving healthcare delivery. RESULTS Using EHDViz, we prototyped clinical dashboards to demonstrate the contextual versatility of EHDViz toolkit. An outpatient cohort was used to visualise population health management tasks (n=14,221), and an inpatient cohort was used to visualise real-time acuity risk in a clinical unit (n=445), and a quantified-self example using wellness data from a fitness activity monitor worn by a single individual was also discussed (n-of-1). The back-end system retrieves relevant data from data source, populates the main panel of the application and integrates user-defined data features in real-time and renders output using modern web browsers. The visualisation elements can be customised using health features, disease names, procedure names or medical codes to populate the visualisations. The source code of EHDViz and various prototypes developed using EHDViz are available in the public domain at http://ehdviz.dudleylab.org. CONCLUSIONS Collaborative data visualisations, wellness trend predictions, risk estimation, proactive acuity status monitoring and knowledge of complex disease indicators are essential components of implementing data-driven precision medicine. As an open-source visualisation framework capable of integrating health assessment, EHDViz aims to be a valuable toolkit for rapid design, development and implementation of scalable clinical data visualisation dashboards.
Collapse
Affiliation(s)
- Marcus A Badgeley
- Harris Center for Precision Wellness, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Khader Shameer
- Harris Center for Precision Wellness, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Benjamin S Glicksberg
- Harris Center for Precision Wellness, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Max S Tomlinson
- Harris Center for Precision Wellness, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Matthew A Levin
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Patrick J McCormick
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Andrew Kasarskis
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - David L Reich
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| | - Joel T Dudley
- Harris Center for Precision Wellness, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
| |
Collapse
|
17
|
LeBlanc A, Herrin J, Williams MD, Inselman JW, Branda ME, Shah ND, Heim EM, Dick SR, Linzer M, Boehm DH, Dall-Winther KM, Matthews MR, Yost KJ, Shepel KK, Montori VM. Shared Decision Making for Antidepressants in Primary Care: A Cluster Randomized Trial. JAMA Intern Med 2015; 175:1761-70. [PMID: 26414670 PMCID: PMC4754973 DOI: 10.1001/jamainternmed.2015.5214] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE For antidepressants, the translation of evidence of comparative effectiveness into practice is suboptimal. This deficit directly affects outcomes and quality of care for patients with depression. To overcome this problem, we developed the Depression Medication Choice (DMC) encounter decision aid, designed to help patients and clinicians consider the available antidepressants and the extent to which they improved depression and other issues important to patients. OBJECTIVE Estimate the effect of DMC on quality of the decision-making process and depression outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted a cluster randomized trial of adults with moderate to severe depression considering treatment with an antidepressant. Primary care practices in 10 rural, suburban, and urban primary care practices across Minnesota and Wisconsin were randomly allocated to treatment of depression with or without use of the DMC decision aid. INTERVENTION Depression Medication Choice, a series of cards, each highlighting the effect of the available options on an issue of importance to patients for use during face-to-face consultations. MAIN OUTCOMES AND MEASURES Decision-making quality as judged by patient knowledge and involvement in decision making, patient and clinician decisional comfort (Decisional Conflict Scale) and satisfaction, encounter duration, medication adherence, depression symptoms, and the Patient Health Questionnaire for depression (PHQ-9). RESULTS We enrolled 117 clinicians and 301 patients (67% women; mean [SD] age, 44 [15] years; mean [SD] PHQ-9 score, 15 [4]) into the trial. Compared with usual care (UC), use of DMC significantly improved patients' decisional comfort (DMC, 80% vs UC, 75%; P = .02), knowledge (DMC, 65% vs UC, 56%; P = .03), satisfaction (risk ratio [RR], from 1.25 [P = .81] to RR, 2.4 [P = .002] depending on satisfaction domain), and involvement (DMC, 47% vs UC, 33%; P<.001). It also improved clinicians' decisional comfort (DMC, 80% vs UC, 68%; P < .001) and satisfaction (RR, 1.64; P = .02). There were no differences in encounter duration, medication adherence, or improvement of depression control between arms. CONCLUSIONS AND RELEVANCE The DMC decision aid helped primary care clinicians and patients with moderate to severe depression select antidepressants together, improving the decision-making process without extending the visit. On the other hand, DMC had no discernible effect on medication adherence or depression outcomes. By translating comparative effectiveness into patient-centered care, use of DMC improved the quality of primary care for patients with depression. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01502891.
Collapse
Affiliation(s)
- Annie LeBlanc
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Robert D. and Patricia E. Kern Mayo Clinic Center for the Scie
| | - Jeph Herrin
- Yale University School of Medicine, New Haven, Connecticut5Health Research & Educational Trust, Chicago, Illinois
| | - Mark D Williams
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Jonathan W Inselman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Megan E Branda
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Emma M Heim
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Sara R Dick
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Mark Linzer
- Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Deborah H Boehm
- Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Kristen M Dall-Winther
- Department of Family Medicine, Mayo Clinic Health Systems-Franciscan Healthcare, La Crosse, Wisconsin
| | - Marc R Matthews
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kathleen J Yost
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kathryn K Shepel
- Media Support Services Division, Mayo Clinic, Rochester, Minnesota
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota12Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
18
|
Concannon TW, Fuster M, Saunders T, Patel K, Wong JB, Leslie LK, Lau J. A systematic review of stakeholder engagement in comparative effectiveness and patient-centered outcomes research. J Gen Intern Med 2014; 29:1692-701. [PMID: 24893581 PMCID: PMC4242886 DOI: 10.1007/s11606-014-2878-x] [Citation(s) in RCA: 305] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 01/16/2014] [Accepted: 04/19/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We conducted a review of the peer-reviewed literature since 2003 to catalogue reported methods of stakeholder engagement in comparative effectiveness research and patient-centered outcomes research. METHODS AND RESULTS We worked with stakeholders before, during and after the review was conducted to: define the primary and key research questions; conduct the literature search; screen titles, abstracts and articles; abstract data from the articles; and analyze the data. The literature search yielded 2,062 abstracts. The review was conducted on 70 articles that reported on stakeholder engagement in individual research projects or programs. FINDINGS Reports of stakeholder engagement are highly variable in content and quality. We found frequent engagement with patients, modestly frequent engagement with clinicians, and infrequent engagement with stakeholders in other key decision-making groups across the healthcare system. Stakeholder engagement was more common in earlier (prioritization) than in later (implementation and dissemination) stages of research. The roles and activities of stakeholders were highly variable across research and program reports. RECOMMENDATIONS To improve on the quality and content of reporting, we developed a 7-Item Stakeholder Engagement Reporting Questionnaire. We recommend three directions for future research: 1) descriptive research on stakeholder-engagement in research; 2) evaluative research on the impact of stakeholder engagement on the relevance, transparency and adoption of research; and 3) development and validation of tools that can be used to support stakeholder engagement in future work.
Collapse
|
19
|
Morrato EH, Concannon TW, Meissner P, Shah ND, Turner BJ. Dissemination and implementation of comparative effectiveness evidence: key informant interviews with Clinical and Translational Science Award institutions. J Comp Eff Res 2014; 2:185-94. [PMID: 24236560 DOI: 10.2217/cer.13.10] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To identify ongoing practices and opportunities for improving national comparative effectiveness research (CER) translation through dissemination and implementation (D&I) via NIH-funded Clinical and Translational Science Award (CTSA) institutions. MATERIALS & METHODS Key informant interviews were conducted with 18 CTSA grantees sampled to represent a range of D&I efforts. RESULTS & CONCLUSIONS The institutional representatives endorsed fostering CER translation nationally via the CTSA Consortium. However, five themes emerged from the interviews as barriers to CER D&I: lack of institutional awareness, insufficient capacity, lack of established D&I methods, confusion among stakeholders about what CER actually is and limited funding opportunities. Interviewees offered two key recommendations to improve CER translation: development of a centralized clearing house to facilitate the diffusion of CER D&I resources and methods across CTSA institutions; and formalization of the national CTSA network to leverage existing community engagement relationships and resources for the purpose of adapting and disseminating robust CER evidence locally with providers, patients and healthcare systems.
Collapse
Affiliation(s)
- Elaine H Morrato
- Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, CO, USA.
| | | | | | | | | |
Collapse
|
20
|
Graffigna G, Barello S, Libreri C, Bosio CA. How to engage type-2 diabetic patients in their own health management: implications for clinical practice. BMC Public Health 2014; 14:648. [PMID: 24966036 PMCID: PMC4083034 DOI: 10.1186/1471-2458-14-648] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 06/15/2014] [Indexed: 12/22/2022] Open
Abstract
Background Patient engagement (PE) is increasingly regarded as a key factor in the improvement of health behaviors and outcomes in the management of chronic disease, such as type 2 diabetes. This article explores (1) the reasons for disengagement of diabetic patients and their unique subjective attitudes from their experience and (2) the elements that may hinder PE in health management. Methods 29 Type-2 uncontrolled diabetes patients were asked to keep a one-week diary related to their experience of disease management, according to the narrative inquiry qualitative approach. They were interviewed to ascertain reasons for PE. The elicited narratives were subjected to interpretive content analysis. Results The findings suggest that patients give meaning to their diabetes and its management through a complex frame of subjective experiential dimensions (cognitive/thinking, behavioral/conative and emotional/feeling), which have an impact on the spheres of daily life that are considered to be crucial in the management of diabetes (diet, physical activity, therapy, doctor-patient relationship) for each patient. These results suggest that PE develops along a continuum featuring four subsequent phases (blackout, arousal, adhesion, eudaimonic project). Several unmet needs related to the different phases of the PE continuum were discovered and illuminated possible types of support. Conclusions Our findings appear to confirm some features of PE detected by previous research, such as a behavioral component. We were also able to shed light on the synergic roles played by other subjective dimensions of patient experience (the cognitive/thinking and the emotional/feeling components) in orienting PE towards the care process. The article suggests a possible framework to deeply understand the PE process useful to orient really attuned actions to support it. These results suggest the importance of developing patient engagement assessment tools that are more firmly grounded in the individual patient experience.
Collapse
Affiliation(s)
- Guendalina Graffigna
- Faculty of Psychology, Università Cattolica del Sacro Cuore, Largo Gemelli 1, Milan 20123, Italy.
| | | | | | | |
Collapse
|
21
|
Gionfriddo MR, Leppin AL, Brito JP, Leblanc A, Shah ND, Montori VM. Shared decision-making and comparative effectiveness research for patients with chronic conditions: an urgent synergy for better health. J Comp Eff Res 2014; 2:595-603. [PMID: 24236798 DOI: 10.2217/cer.13.69] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chronic conditions are the most important cause of morbidity, mortality and health expense in the USA. Comparative effectiveness research (CER) seeks to provide evidence supporting the relative value of alternative courses of action. This research often concludes with estimates of the likelihood of desirable and undesirable outcomes associated with each option. Patients with chronic conditions should engage with their clinicians in deciding which of these options best fits their goals and context. In practicing shared decision-making (SDM), clinicians and patients should make use of CER to inform their deliberations. In these ways, SDM and CER are interrelated. SDM translates CER into patient-centered practice, while CER provides the backbone evidence about options and outcomes in SDM interventions. In this review, we explore the potential for a SDM-CER synergy in improving healthcare for patients with chronic conditions.
Collapse
Affiliation(s)
- Michael R Gionfriddo
- Knowledge & Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
22
|
Coylewright M, Branda M, Inselman JW, Shah N, Hess E, LeBlanc A, Montori VM, Ting HH. Impact of sociodemographic patient characteristics on the efficacy of decision AIDS: a patient-level meta-analysis of 7 randomized trials. Circ Cardiovasc Qual Outcomes 2014; 7:360-7. [PMID: 24823953 DOI: 10.1161/hcq.0000000000000006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Decision aids (DAs) increase patient knowledge, reduce decisional conflict, and promote shared decision making (SDM). The extent to which they do so across diverse sociodemographic patient groups is unknown. METHODS AND RESULTS We conducted a patient-level meta-analysis of 7 randomized trials of DA versus usual care comprising 771 encounters between patients and clinicians discussing treatment options for chest pain, myocardial infarction, diabetes mellitus, and osteoporosis. Using a random effects model, we examined the impact of sociodemographic patient characteristics (age, sex, education, income, and insurance status) on the outcomes of knowledge transfer, decisional conflict, and patient involvement in SDM. Because of small numbers of people of color in the study population, we were not powered to investigate the role of race. Most patients were aged ≥65 years (61%), white (94%), and women (59%); two thirds had greater than a high school education. Compared with usual care, DA patients gained knowledge, were more likely to know their risk, and had less decisional conflict along with greater involvement in SDM. These gains were largely consistent across sociodemographic patient groups, with DAs demonstrating similar efficacy when used with vulnerable patients such as the elderly and those with less income and less formal education. Differences in efficacy were found only in knowledge of risk in 1 subgroup, with greater efficacy among those with higher education (35% versus 18%; P=0.02). CONCLUSIONS In this patient-level meta-analysis of 7 randomized trials, DAs were efficacious across diverse sociodemographic groups as measured by knowledge transfer, decisional conflict, and patient involvement in SDM. To the extent that DAs increase patient knowledge and participation in SDM, they have potential to impact health disparities related to these factors.
Collapse
Affiliation(s)
- Megan Coylewright
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Megan Branda
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Nilay Shah
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Erik Hess
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Annie LeBlanc
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Victor M Montori
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN
| | - Henry H Ting
- From the Division of Cardiovascular Diseases, Department of Medicine (M.C., H.H.T.), Knowledge and Evaluation Research Unit (M.C., M.B., J.W.I., N.S., E.H., A.L., V.M.M., H.H.T.), and Divisions of Health Care Policy and Research, Department of Health Sciences Research (N.S.), Emergency Medicine Research, Department of Emergency Medicine (E.H.), and Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN.
| |
Collapse
|
23
|
Sheridan SL, Draeger LB, Pignone MP, Rimer B, Bangdiwala SI, Cai J, Gizlice Z, Keyserling TC, Simpson RJ. The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial. BMC Med Inform Decis Mak 2014; 14:14. [PMID: 24575882 PMCID: PMC3943405 DOI: 10.1186/1472-6947-14-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/10/2014] [Indexed: 04/01/2024] Open
Abstract
Background Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease (CHD) prevention medications and help patients choose medications to which they are likely to adhere. However, little data is available on decision aids designed to promote adherence. Methods In this paper, we report on secondary analyses of a randomized trial of a CHD adherence intervention (second generation decision aid plus tailored messages) versus usual care in an effort to understand how the decision aid facilitates adherence. We focus on data collected from the primary study visit, when intervention participants presented 45 minutes early to a previously scheduled provider visit; viewed the decision aid, indicating their intent for CHD risk reduction after each decision aid component (individualized risk assessment and education, values clarification, and coaching); and filled out a post-decision aid survey assessing their knowledge, perceived risk, decisional conflict, and intent for CHD risk reduction. Control participants did not present early and received usual care from their provider. Following the provider visit, participants in both groups completed post-visit surveys assessing the number and quality of CHD discussions with their provider, their intent for CHD risk reduction, and their feelings about the decision aid. Results We enrolled 160 patients into our study (81 intervention, 79 control). Within the decision aid group, the decision aid significantly increased knowledge of effective CHD prevention strategies (+21 percentage points; adjusted p<.0001) and the accuracy of perceived CHD risk (+33 percentage points; adjusted p<.0001), and significantly decreased decisional conflict (-0.63; adjusted p<.0001). Comparing between study groups, the decision aid also significantly increased CHD prevention discussions with providers (+31 percentage points; adjusted p<.0001) and improved perceptions of some features of patient-provider interactions. Further, it increased participants’ intentions for any effective CHD risk reducing strategies (+21 percentage points; 95% CI 5 to 37 percentage points), with a majority of the effect from the educational component of the decision aid. Ninety-nine percent of participants found the decision aid easy to understand and 93% felt it easy to use. Conclusions Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussions and intent to reduce CHD risk.
Collapse
Affiliation(s)
- Stacey L Sheridan
- Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, NC USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Eton DT, Beebe TJ, Hagen PT, Halyard MY, Montori VM, Naessens JM, Sloan JA, Thompson CA, Wood DL. Harmonizing and consolidating the measurement of patient-reported information at health care institutions: a position statement of the Mayo Clinic. PATIENT-RELATED OUTCOME MEASURES 2014; 5:7-15. [PMID: 24550683 PMCID: PMC3926456 DOI: 10.2147/prom.s55069] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Patient-reported outcomes (PROs) capture how patients perceive their health and their health care; their use in clinical research is longstanding. Today, however, PROs increasingly are being used to inform the care of individual patients, and document the performance of health care entities. We recently wrote and internally distributed an institutional position statement titled “Harmonizing and Consolidating the Measurement of Patient-Reported Outcomes at Mayo Clinic: A Position Statement for the Center for the Science of Health Care Delivery”. The statement is meant to educate clinicians, clinical teams, and institutional administrators about the merits of using PROs in a systematic manner for clinical care and quality measurement throughout the institution. The present article summarizes the most important messages from the statement, describing PROs and their use, identifying practical considerations for implementing them in routine practice, elucidating potential barriers to their use, and formulating strategies to overcome these barriers. The lessons learned from our experience – including pitfalls, challenges, and successes – may inform other health care institutions that are interested in systematically using PROs in health care delivery science and practice.
Collapse
Affiliation(s)
- David T Eton
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Timothy J Beebe
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Philip T Hagen
- Department of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Victor M Montori
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Knowledge and Evaluation Research Unit, Rochester, MN, USA
| | - James M Naessens
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Jeff A Sloan
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Rochester, MN, USA
| | | | - Douglas L Wood
- Division of Heath Care Policy and Research, Department of Health Sciences Research, Rochester, MN, USA ; Center for Innovation, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
25
|
Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood) 2013; 32:276-84. [PMID: 23381520 DOI: 10.1377/hlthaff.2012.1078] [Citation(s) in RCA: 516] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- France Légaré
- Department of Family and Emergency Medicine at Université Laval, Quebec City, Quebec.
| | | |
Collapse
|
26
|
von Websky K, Reichetzeder C, Hocher B. Linagliptin as add-on therapy to insulin for patients with type 2 diabetes. Vasc Health Risk Manag 2013; 9:681-94. [PMID: 24204157 PMCID: PMC3818026 DOI: 10.2147/vhrm.s40035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a highly prevalent, progressive disease that often is poorly controlled. The combination of an incretin-based therapy and insulin is a promising approach to optimize the management of glycemic control without hypoglycemia and weight gain. Linagliptin, a recently approved oral dipeptidyl peptidase-4 inhibitor, has a unique pharmacological profile. The convenient, once-daily dosing does not need adjustment in patients with hepatic and/or renal impairment. In clinical studies linagliptin shows an important reduction of blood glucose with an overall safety profile similar to that of placebo. So far, the combination of linagliptin and insulin has been tested in three major clinical studies in different populations. It has been shown that linagliptin is an effective and safe add-on therapy to insulin in patients with T2DM. The efficacy and safety of this combination was also shown in vulnerable, elderly T2DM patients and in patients with T2DM and renal impairment. Favorable effects regarding the counteraction of hypoglycemia make linagliptin especially interesting as an add-on therapy to insulin. This review aims to present the existing clinical studies on the efficacy and safety of linagliptin as add-on therapy to insulin in patients with T2DM in the context of current literature. Additionally, the possible advantages of linagliptin as an add-on therapy to insulin in relation to cardiovascular safety, patient-centered therapy and the prevention of hypoglycemia, are discussed.
Collapse
Affiliation(s)
- Karoline von Websky
- Institute of Nutritional Science, University of Potsdam, Potsdam-Rehbrücke, Germany
| | | | | |
Collapse
|
27
|
LeBlanc A, Bodde AE, Branda ME, Yost KJ, Herrin J, Williams MD, Shah ND, Houten HV, Ruud KL, Pencille LJ, Montori VM. Translating comparative effectiveness of depression medications into practice by comparing the depression medication choice decision aid to usual care: study protocol for a randomized controlled trial. Trials 2013; 14:127. [PMID: 23782672 PMCID: PMC3663744 DOI: 10.1186/1745-6215-14-127] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 04/17/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Comparative effectiveness research (CER) documents important differences in antidepressants in terms of efficacy, safety, cost, and burden to the patient. Decision aids can adapt this evidence to help patients participate in making informed choices. In turn, antidepressant therapy will more likely reflect patients' values and context, leading to improved adherence and mood outcomes. METHODS/DESIGN The objective of this study is to develop the Depression Medication Choice decision aid for use during primary care encounters, and to test its efficacy by conducting a clustered practical randomized trial comparing the decision aid to usual depression care in primary care practices.We will use a novel practice-based, patient-centered approach based on participatory action research that involves a multidisciplinary team of designers, investigators, clinicians, patient representatives, and other stakeholders for the development of the decision aid. We will then conduct a clustered practical randomized trial enrolling clinicians and their patients (n = 300) with moderate to severe depression from rural, suburban and inner city primary care practices (n = 10). The intervention will consist of the use of the depression medication choice decision aid during the clinical encounter. This trial will generate preliminary evidence of the relative impact of the decision aid on patient involvement in decision making, decision making quality, patient knowledge, and 6-month measures of medication adherence and mental health compared to usual depression care. DISCUSSION Upon completion of the proposed research, we will have developed and evaluated the efficacy of the decision aid depression medication choice as a novel translational tool for CER in depression treatment, engaged patients with depression in their care, and refined the process by which we conduct practice-based trials with limited research footprint. TRIAL REGISTRATION Clinical Trials.gov: NCT01502891.
Collapse
Affiliation(s)
- Annie LeBlanc
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Cornell SA. A patient-centred approach to treatment with incretin-based agents in patients with type 2 diabetes. J Clin Pharm Ther 2013; 38:181-9. [PMID: 23442106 DOI: 10.1111/jcpt.12040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 12/06/2012] [Indexed: 12/25/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The 2012 position statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) recommends a haemoglobin A1c level of <7% for most patients with type 2 diabetes (T2D). Initial therapy consists of lifestyle changes plus metformin, with an emphasis on a patient-centred approach to management. Addition of incretin-based therapy is recommended as an add-on after metformin failure, and later on in combination with basal insulin. Basal insulin is recommended from the onset in patients with A1c ≥10%. The possibility of incorporating incretin-based therapy in the patient-centred approach will be investigated both in the literature and clinical experience. COMMENT Incretin-based therapy targets multiple dysfunctional organ systems in T2D and provides sustained glycaemic control, with extraglycaemic benefits and low risk of hypoglycaemia. To initiate an incretin-based therapy that best fits an individual patient's needs, the patient's A1c level, preference and comorbid conditions should be considered along with any drug safety and adherence-related issues. WHAT IS NEW AND CONCLUSION There is good evidence to support the patient-centred approach to T2D management. This approach allows patient treatment goals and personal preferences to be matched with the clinical profile(s) of one or more agents to formulate a treatment plan that can best achieve the goals. Incretin-based therapies are an important class of agents to consider after metformin monotherapy failure and later in combination with basal insulin. By matching patient needs with the clinical profiles of the various treatment options, pharmacists can actively engage in the practice of patient-centred care and management.
Collapse
Affiliation(s)
- Susan A Cornell
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL 60515, USA.
| |
Collapse
|
29
|
Politi MC, Clayman ML, Fagerlin A, Studts JL, Montori V. Insights from a conference on implementing comparative effectiveness research through shared decision-making. J Comp Eff Res 2013; 2:23-32. [PMID: 23430243 PMCID: PMC3575182 DOI: 10.2217/cer.12.67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
For decades, investigators have conducted innovative research on shared decision-making (SDM), helping patients and clinicians to discuss health decisions and balance evidence with patients' preferences for possible outcomes of options. In addition, investigators have developed and used rigorous methods for conducting comparative effectiveness research (CER), comparing the benefits and risks of different interventions in real-world settings with outcomes that matter to patients and other stakeholders. However, incorporating CER findings into clinical practice presents numerous challenges. In March 2012, we organized a conference at Washington University in St Louis (MO, USA) aimed at developing a network of researchers to collaborate in developing, conducting and disseminating research about the implementation of CER through SDM. Meeting attendees discussed conceptual similarities and differences between CER and SDM, challenges in implementing CER and SDM in practice, specific challenges when engaging SDM with unique populations and examples of ways to overcome these challenges. CER and SDM are related processes that emphasize examining the best clinical evidence and how it applies to real patients in real practice settings. SDM can provide one opportunity for clinicians to discuss CER findings with patients and engage in a dialog about how to manage uncertainty about evidence in order to make decisions on an individual patient level. This meeting highlighted key challenges and suggested avenues to pursue such that CER and SDM can be implemented into routine clinical practice.
Collapse
Affiliation(s)
- Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University in St Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8100, St Louis, MO 63110, USA
| | - Marla L Clayman
- Department of Medicine, Division of General Internal Medicine, Northwestern University, Feinberg School of Medicine, IL, USA
| | - Angela Fagerlin
- Department of Internal Medicine & Center for Bioethics & Social Sciences in Medicine, University of Michigan School of Medicine, VA Ann Arbor Center for Clinical Management Research, MI, USA
| | - Jamie L Studts
- Department of Behavioral Science, University of Kentucky College of Medicine, KY, USA
| | - Victor Montori
- Department of Health Sciences Research, Division of Health Care & Policy Research, & Knowledge & Evaluation Research Unit, Mayo Clinic, MN, USA
| |
Collapse
|
30
|
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012; 55:1577-96. [PMID: 22526604 DOI: 10.1007/s00125-012-2534-0] [Citation(s) in RCA: 989] [Impact Index Per Article: 82.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 02/24/2012] [Indexed: 12/11/2022]
Affiliation(s)
- S E Inzucchi
- Section of Endocrinology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012; 35:1364-79. [PMID: 22517736 PMCID: PMC3357214 DOI: 10.2337/dc12-0413] [Citation(s) in RCA: 2554] [Impact Index Per Article: 212.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Helfand M, Tunis S, Whitlock EP, Pauker SG, Basu A, Chilingerian J, Harrell FE, Meltzer DO, Montori VM, Shepard DS, Kent DM. A CTSA agenda to advance methods for comparative effectiveness research. Clin Transl Sci 2011; 4:188-98. [PMID: 21707950 PMCID: PMC4567896 DOI: 10.1111/j.1752-8062.2011.00282.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Clinical research needs to be more useful to patients, clinicians, and other decision makers. To meet this need, more research should focus on patient-centered outcomes, compare viable alternatives, and be responsive to individual patients' preferences, needs, pathobiology, settings, and values. These features, which make comparative effectiveness research (CER) fundamentally patient-centered, challenge researchers to adopt or develop methods that improve the timeliness, relevance, and practical application of clinical studies. In this paper, we describe 10 priority areas that address 3 critical needs for research on patient-centered outcomes (PCOR): (1) developing and testing trustworthy methods to identify and prioritize important questions for research; (2) improving the design, conduct, and analysis of clinical research studies; and (3) linking the process and outcomes of actual practice to priorities for research on patient-centered outcomes. We argue that the National Institutes of Health, through its clinical and translational research program, should accelerate the development and refinement of methods for CER by linking a program of methods research to the broader portfolio of large, prospective clinical and health system studies it supports. Insights generated by this work should be of enormous value to PCORI and to the broad range of organizations that will be funding and implementing CER.
Collapse
Affiliation(s)
- Mark Helfand
- Oregon Clinical & Translational Research Center, Oregon Health & Sciences University, and Department of Hospital and Specialty Medicine, The Portland VA Medical Center, Portland, OR, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Frosch DL, Moulton BW, Wexler RM, Holmes-Rovner M, Volk RJ, Levin CA. Shared decision making in the United States: policy and implementation activity on multiple fronts. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2011; 105:305-12. [DOI: 10.1016/j.zefq.2011.04.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
34
|
Wang AT, Wang JK, Montori VM, Murad MH. Comparative effectiveness research in urology. World J Urol 2010; 29:277-82. [PMID: 21188385 DOI: 10.1007/s00345-010-0637-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 12/11/2010] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Comparative effectiveness research (CER) has come to remain at the forefront of political and scientific debates of health care. The aim of this article is to describe the attributes of CER and implications to the field of urology. METHODS The authors reviewed the published urology literature and recent CER publications including the Institute of Medicine reports. RESULTS CER is defined as the evaluation of the relative efficacy of diagnostic tests, treatments, and health care services against the current standards of care, with the goal of reducing health care costs while simultaneously improving quality. Significant government funds were recently devoted to CER efforts. The Institute of Medicine identified 25 of the most urgently needed areas for research of which three pertain to Urology: screening for prostate cancer, comparing effectiveness of treatments for localized prostate cancer, and use of imaging in diagnosing, staging, and monitoring cancer patients. Some of the important required strategies to formulate successful CER include involving health care stakeholders to aid in selecting appropriate topics, utilizing study populations that represent real life practice, and the development of large-scale national databases and registries. CONCLUSION Several topics of urologic care have already been identified in the first quartile of CER priorities, and many others need to be added. Following the proposed research, designs for CER should be done while abiding by robust methodology, maintaining transparency, and effectively translating research into clinical practice.
Collapse
Affiliation(s)
- Amy T Wang
- Knowledge and Encounter Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | | | | |
Collapse
|
35
|
|