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Mack DP, Greenhawt M, Bukstein DA, Golden DBK, Settipane RA, Davis RS. Decisions With Patients, Not for Patients: Shared Decision-Making in Allergy and Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00577-4. [PMID: 38851489 DOI: 10.1016/j.jaip.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
Shared decision-making (SDM) is an increasingly implemented patient-centered approach to navigating patient preferences regarding diagnostic and treatment options and supported decision-making. This therapeutic approach prioritizes the patient's perspectives, considering current medical evidence to provide a balanced approach to clinical scenarios. In light of numerous recent guideline recommendations that are conditional in nature and are clinical scenarios defined by preference-sensitive care options, there is a tremendous opportunity for SDM and validated decision aids. Despite the expansion of the literature on SDM, formal acceptance among clinicians remains inconsistent. Surprisingly, a significant disparity exists between clinicians' self-reported adherence to SDM principles and patients' perceptions of its implementation during clinical encounters. This discrepancy underscores a fundamental issue in the delivery of health care, where clinicians may overestimate their integration of SDM, while patients' experiences suggest otherwise. This review critically examines the factors contributing to this inconsistency, including barriers within the health care system, clinician attitudes and behaviors, and patient expectations and preferences. By elucidating these factors in the fields of food allergy, asthma, eosinophilic esophagitis, and other allergic diseases, this review aims to provide insights into bridging the gap between clinician perception and patient experience in SDM. Addressing this discordance is crucial for advancing patient-centered care and ensuring that SDM is not merely a theoretical concept but a tangible reality in the.
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Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Don A Bukstein
- The Inner City Milwaukee Clinic, Allergy, Asthma & Sinus Center, Milwaukee, Wisc
| | - David B K Golden
- Department of Pediatrics, Johns Hopkins University, Baltimore, Md
| | - Russell A Settipane
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI
| | - Ray S Davis
- Division of Allergy Immunology & Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
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Asthana S, Walker J, Staub J, Bajaj P, Reyes S, Shlobin NA, Beestrum M, Hsu WK, Patel AA, Divi SN. Preference Sensitive Care and Shared Decision-Making in Lumbar Spinal Stenosis: A Scoping Review. Spine (Phila Pa 1976) 2024; 49:788-797. [PMID: 38369716 DOI: 10.1097/brs.0000000000004952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/27/2024] [Indexed: 02/20/2024]
Abstract
STUDY DESIGN Scoping review. OBJECTIVE The objective of this study was to conduct a scoping review exploring the extent to which preference sensitivity has been studied in treatment decisions for lumbar spinal stenosis (LSS), utilizing shared decision-making (SDM) as a proxy. BACKGROUND Preference-sensitive care involves situations where multiple treatment options exist with significant tradeoffs in cost, outcome, recovery time, and quality of life. LSS has gained research focus as a preference-sensitive care scenario. MATERIALS AND METHODS A scoping review protocol in accordance with "Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews" regulations was registered with the Open Science Framework (ID: 9ewup) and conducted across multiple databases from January 2000 to October 2022. Study selection and characterization were performed by 3 independent reviewers and an unbiased moderator. RESULTS The search resulted in the inclusion of 16 studies varying in design and sample size, with most published between 2016 and 2021. The studies examined variables related to SDM, patient preferences, surgeon preferences, and decision aids (DAs). The outcomes assessed included treatment choice, patient satisfaction, and patient understanding. Several studies reported that SDM influenced treatment choice and patient satisfaction, while the impact on patient understanding was less clear. DAs were used in some studies to facilitate SDM. CONCLUSION The scoping review identified a gap in comprehensive studies analyzing the preference sensitivity of treatment for LSS and the role of DAs. Further research is needed to better understand the impact of patient preferences on treatment decisions and the effectiveness of DAs in LSS care. This review provides a foundation for future research in preference-sensitive care and SDM in the context of lumbar stenosis treatment.
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Affiliation(s)
- Shravan Asthana
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James Walker
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacob Staub
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Pranav Bajaj
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Samuel Reyes
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nathan A Shlobin
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Molly Beestrum
- Department of Research and Information Services, Galter Health Sciences Library and Learning Center, Feinberg School of Medicine, Chicago, IL
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Srikanth N Divi
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Hoffmann C, Avery K, Macefield R, Dvořák T, Snelgrove V, Blazeby J, Hopkins D, Hickey S, Gibbison B, Rooshenas L, Williams A, Aning J, Bekker HL, McNair AG. Usability of an Automated System for Real-Time Monitoring of Shared Decision-Making for Surgery: Mixed Methods Evaluation. JMIR Hum Factors 2024; 11:e46698. [PMID: 38598276 PMCID: PMC11043934 DOI: 10.2196/46698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 10/02/2023] [Accepted: 03/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Improving shared decision-making (SDM) for patients has become a health policy priority in many countries. Achieving high-quality SDM is particularly important for approximately 313 million surgical treatment decisions patients make globally every year. Large-scale monitoring of surgical patients' experience of SDM in real time is needed to identify the failings of SDM before surgery is performed. We developed a novel approach to automating real-time data collection using an electronic measurement system to address this. Examining usability will facilitate its optimization and wider implementation to inform interventions aimed at improving SDM. OBJECTIVE This study examined the usability of an electronic real-time measurement system to monitor surgical patients' experience of SDM. We aimed to evaluate the metrics and indicators relevant to system effectiveness, system efficiency, and user satisfaction. METHODS We performed a mixed methods usability evaluation using multiple participant cohorts. The measurement system was implemented in a large UK hospital to measure patients' experience of SDM electronically before surgery using 2 validated measures (CollaboRATE and SDM-Q-9). Quantitative data (collected between April 1 and December 31, 2021) provided measurement system metrics to assess system effectiveness and efficiency. We included adult patients booked for urgent and elective surgery across 7 specialties and excluded patients without the capacity to consent for medical procedures, those without access to an internet-enabled device, and those undergoing emergency or endoscopic procedures. Additional groups of service users (group 1: public members who had not engaged with the system; group 2: a subset of patients who completed the measurement system) completed user-testing sessions and semistructured interviews to assess system effectiveness and user satisfaction. We conducted quantitative data analysis using descriptive statistics and calculated the task completion rate and survey response rate (system effectiveness) as well as the task completion time, task efficiency, and relative efficiency (system efficiency). Qualitative thematic analysis identified indicators of and barriers to good usability (user satisfaction). RESULTS A total of 2254 completed surveys were returned to the measurement system. A total of 25 service users (group 1: n=9; group 2: n=16) participated in user-testing sessions and interviews. The task completion rate was high (169/171, 98.8%) and the survey response rate was good (2254/5794, 38.9%). The median task completion time was 3 (IQR 2-13) minutes, suggesting good system efficiency and effectiveness. The qualitative findings emphasized good user satisfaction. The identified themes suggested that the measurement system is acceptable, easy to use, and easy to access. Service users identified potential barriers and solutions to acceptability and ease of access. CONCLUSIONS A mixed methods evaluation of an electronic measurement system for automated, real-time monitoring of patients' experience of SDM showed that usability among patients was high. Future pilot work will optimize the system for wider implementation to ultimately inform intervention development to improve SDM. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2023-079155.
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Affiliation(s)
- Christin Hoffmann
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Kerry Avery
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Rhiannon Macefield
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Tadeáš Dvořák
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | | | - Jane Blazeby
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | | | - Shireen Hickey
- Improvement Academy, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Ben Gibbison
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Leila Rooshenas
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | | | | | - Hilary L Bekker
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
- The Research Centre for Patient Involvement (ResCenPI), Department of Public Health, Aarhus University, Central Denmark Region, Denmark
| | - Angus Gk McNair
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
- North Bristol NHS Trust, Bristol, United Kingdom
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Andringa A, Veerkamp K, Roebroeck M, Ketelaar M, Klem M, Dekkers H, Voorman J, van Driel M, Buizer A. Combined surveillance and treatment register for children with cerebral palsy: the protocol of the Netherlands CP register. BMJ Open 2023; 13:e076619. [PMID: 37898490 PMCID: PMC10619026 DOI: 10.1136/bmjopen-2023-076619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/03/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Cerebral palsy (CP) is a childhood onset, lifelong, condition. Early detection and timely treatment of potential problems during the child's development are important to prevent secondary impairments and improve function. Clinical management of children with CP requires a spectrum of multidisciplinary interventions, which have an impact on short-term and long-term outcomes. However, there is a lack of knowledge about a personalised approach in this heterogeneous population. Various CP registers with different aims have been developed worldwide, which has made an important contribution to our understanding of CP. The purpose of this protocol is to describe the unique design of a combined multidisciplinary surveillance and treatment register for children with CP in the Netherlands, which aims to improve quality of care and to enhance an individual treatment approach. METHODS AND ANALYSIS The Netherlands CP Register combines a multidisciplinary surveillance programme with a standardised protocol for treatment registry. The register systematically collects real-life surveillance and treatment data of children with CP. The register contributes to daily care at the individual level by screening for potential secondary impairments using a decision-support tool, by visualising individual development using a dashboard, and by supporting goal setting and shared decision-making for interventions. The register provides a platform at the national level for quality of care improvement and a comprehensive database of real-life data allowing multicentre studies with a long-term follow-up. People with lived experience of CP, healthcare professionals from different disciplines and researchers collaborated in the development of the register. ETHICS AND DISSEMINATION The Netherlands CP register was submitted to the Medical Ethics Review Committee of VU University Medical Center (Amsterdam, the Netherlands), who judged the register not to be subject to the Medical Research Involving Human Subjects Act. A scientific board reviews requests for dissemination of data from the register for specific research questions.
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Affiliation(s)
- Aukje Andringa
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
| | - Kirsten Veerkamp
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marij Roebroeck
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre and Rijndam Rehabilitation, Rotterdam, Netherlands
| | - Marjolijn Ketelaar
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- De Hoogstraat Rehabilitation, Utrecht, Netherlands
- Department of Rehabilitation, University Medical Centre Utrecht, Brain Centre, Utrecht, Netherlands
- CP-Net, Utrecht, Netherlands
| | - Martijn Klem
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- CP-Net, Utrecht, Netherlands
- Revalidatie Nederland, Utrecht, Netherlands
| | - Hurnet Dekkers
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands
- Netherlands Society of Rehabilitation Medicine, Utrecht, Netherlands
| | - Jeanine Voorman
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- Department of Rehabilitation, University Medical Centre Utrecht, Brain Centre, Utrecht, Netherlands
- CP-Net, Utrecht, Netherlands
- Netherlands Society of Rehabilitation Medicine, Utrecht, Netherlands
- Department of Rehabilitation, Physiotherapy Sciences and Sport, University Medical Centre Utrecht, location Wilhelmina Children's Hospital and Prinses Máxima Centre for Child Oncology, Utrecht, Netherlands
| | - Marieke van Driel
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- CP Nederland, Houten, Netherlands
| | - Annemieke Buizer
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Steering group of the Netherlands CP register, Amsterdam, Netherlands
- Netherlands Society of Rehabilitation Medicine, Utrecht, Netherlands
- Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
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Hole B, Scanlon M, Tomson C. Shared decision making: a personal view from two kidney doctors and a patient. Clin Kidney J 2023; 16:i12-i19. [PMID: 37711639 PMCID: PMC10497374 DOI: 10.1093/ckj/sfad064] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Indexed: 09/16/2023] Open
Abstract
Shared decision making (SDM) combines the clinician's expertise in the treatment of disease with the patient's expertise in their lived experience and what is important to them. All decisions made in the care of patients with kidney disease can potentially be explored through SDM. Adoption of SDM in routine kidney care faces numerous institutional and practical barriers. Patients with chronic disease who have become accustomed to paternalistic care may need support to engage in SDM-even though most patients actively want more involvement in decisions about their care. Nephrologists often underestimate the risks and overestimate the benefits of investigations and treatments and often default to recommending burdensome treatments rather than discussing prognosis openly. Guideline bodies continue to issue recommendations written for healthcare professionals without providing patient decision aids. To mitigate health inequalities, care needs to be taken to provide SDM to all patients, not just the highly health-literate patients least likely to need additional support in decision making. Kidney doctors spend much of their time in the consulting room, and it is unjustifiable that so little attention is paid to the teaching, audit and maintenance of consultation skills. Writing letters to the patient to summarise the consultation rather than sending them a copy of a letter between health professionals sets the tone for a consultation in which the patient is an active partner. Adoption of SDM will require nephrologists to relinquish long-established paternalistic models of care and restructure care around the values and preferences of patients.
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Affiliation(s)
- Barnaby Hole
- North Bristol NHS Trust, Department of Nephrology, Bristol, UK
- University of Bristol, Bristol Medical School, Bristol, UK
| | - Miranda Scanlon
- North Bristol NHS Trust, Department of Nephrology, Bristol, UK
- Kidney Research UK, Lay Advisory Group, Peterborough, UK
| | - Charlie Tomson
- North Bristol NHS Trust, Department of Nephrology, Bristol, UK
- Kidney Research UK, Board of Trustees, Peterborough, UK
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Hernández-Leal MJ, Pérez-Lacasta MJ, Cardona-Cardona A, Codern-Bové N, Vidal-Lancis C, Rue M, Forné C, Carles-Lavila M. Women's preference to apply shared decision-making in breast cancer screening: a discrete choice experiment. BMJ Open 2022; 12:e064488. [PMID: 36351714 PMCID: PMC9644356 DOI: 10.1136/bmjopen-2022-064488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To analyse women's stated preferences for establishing the relative importance of each attribute of shared decision-making (SDM) and their willingness to pay (WTP) for more participatory care in breast cancer screening programmes (BCSP). DESIGN A discrete choice experiment was designed with 12 questions (choice tasks). It included three attributes: 'How the information is obtained', regarding benefits and harms; whether there is a 'Dialogue for scheduled mammography' between the healthcare professional and the woman; and, 'Who makes the decision', regarding participation in BCSP. Data were obtained using a survey that included 12 choice tasks, 1 question on WTP and 7 socioeconomic-related questions. The analysis was performed using conditional mixed-effect logit regression and stratification according to WTP. SETTING Data collection related to BCSP was conducted between June and November 2021 in Catalonia, Spain. PARTICIPANTS Sixty-five women aged between 50 and 60. MAIN OUTCOME MEASURES Women's perceived utility of each attribute, trade-off on these attributes and WTP for SDM in BCSP. RESULT The only significant attribute was 'Who makes the decision'. The decision made alone (coefficient=2.879; 95% CI=2.297 to 3.461) and the decision made together with a healthcare professional (2.375; 95% CI=1.573 to 3.177) were the options preferred by women. The former contributes 21% more utility than the latter. Moreover, 52.3% of the women stated a WTP of €10 or more for SDM. Women's preferences regarding attributes did not influence their WTP. CONCLUSIONS The participant women refused a current paternalistic model and preferred either SDM or informed decision-making in BCSP.
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Affiliation(s)
- María José Hernández-Leal
- Department of Economics, University Rovira i Virgili, Reus, Spain
- Research Centre on Economics and Sustainability (ECO-SOS), Reus, Spain
- Research Group on Statistics, Economic Evaluation and Health (GRAEES), Reus, Spain
| | - María José Pérez-Lacasta
- Department of Economics, University Rovira i Virgili, Reus, Spain
- Research Group on Statistics, Economic Evaluation and Health (GRAEES), Reus, Spain
| | - Angels Cardona-Cardona
- Area Q: Evaluation and Research in the Field of Social Sciences and Health, Barcelona, Spain
| | - Núria Codern-Bové
- School of Nursing and Occupational Therapy (EUIT), Autonomous University of Barcelona, Terrasa, Spain
| | - Carmen Vidal-Lancis
- Cancer Prevention and Control Program, Catalan Institute of Oncology-IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Montserrat Rue
- Research Group on Statistics, Economic Evaluation and Health (GRAEES), Reus, Spain
- Department of Basic Medical Sciences, University of Lleida-IRB, Lleida, Spain
| | - Carles Forné
- Department of Basic Medical Sciences, University of Lleida, Lleida, Spain
- HEOR freelance consultant, Heorfy Consulting, Reus, Spain
| | - Misericòrdia Carles-Lavila
- Department of Economics, University Rovira i Virgili, Reus, Spain
- Research Centre on Economics and Sustainability (ECO-SOS), Reus, Spain
- Research Group on Statistics, Economic Evaluation and Health (GRAEES), Reus, Spain
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Ossin DA, Carter EC, Cartwright R, Violette PD, Iyer S, Klein GT, Senapati S, Klaassen Z, Botros SM. Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery. Nat Rev Urol 2021; 19:161-170. [PMID: 34931058 DOI: 10.1038/s41585-021-00551-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/09/2022]
Abstract
Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.
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Affiliation(s)
- David A Ossin
- Division of Urogynecology, Department of Urology, University of Texas Health San Antonio, Joe R & Theresa Long School of Medicine, San Antonio, TX, USA.
| | - Emily C Carter
- Department of Obstetrics and Gynaecology, Stoke Mandeville Hospital, Aylesbury, UK
| | - Rufus Cartwright
- Department of Urogynaecology, LNWH NHS Trust, London, UK & Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Philippe D Violette
- Department of Health Research Methods, Evidence and Impact (HEI) and Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shilpa Iyer
- Department of Obstetrics and Gynecology, Section of Female Pelvic Medicine and Reconstructive Surgery, The University of Chicago, Chicago, IL, USA
| | - Geraldine T Klein
- Department of Urology Eisenhower Medical Associates, Rancho Mirage, CA, USA
| | - Sangeeta Senapati
- Department of Obstetrics and Gynecology, Northshore University HealthSystem, Evanston, IL, USA.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Zachary Klaassen
- Division of Urology, Department of Surgery, Augusta University-Medical College of Georgia, Augusta, GA, USA
| | - Sylvia M Botros
- Division of Urogynecology, Department of Urology, University of Texas Health San Antonio, Joe R & Theresa Long School of Medicine, San Antonio, TX, USA
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Chung MK, Fagerlin A, Wang PJ, Ajayi TB, Allen LA, Baykaner T, Benjamin EJ, Branda M, Cavanaugh KL, Chen LY, Crossley GH, Delaney RK, Eckhardt LL, Grady KL, Hargraves IG, Hills MT, Kalscheur MM, Kramer DB, Kunneman M, Lampert R, Langford AT, Lewis KB, Lu Y, Mandrola JM, Martinez K, Matlock DD, McCarthy SR, Montori VM, Noseworthy PA, Orland KM, Ozanne E, Passman R, Pundi K, Roden DM, Saarel EV, Schmidt MM, Sears SF, Stacey D, Stafford RS, Steinberg BA, Wass SY, Wright JM. Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management. Circ Arrhythm Electrophysiol 2021; 14:e007958. [PMID: 34865518 PMCID: PMC8692382 DOI: 10.1161/circep.121.007958] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.
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Affiliation(s)
| | - Angela Fagerlin
- University of Utah, Salt Lake City, UT
- Salt Lake City Veterans Affairs Informatics Decision-Enhancement and Analytic Sciences Center for Innovation, Salt Lake City, UT
| | | | | | | | | | | | - Megan Branda
- University of Colorado, Aurora, CO
- Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | | | | | | | - Marleen Kunneman
- Mayo Clinic, Rochester, MN
- Leiden University Medical Center, Leiden, the Netherlands
| | | | | | | | - Ying Lu
- Stanford University, Stanford, CA
| | | | | | | | | | | | | | | | | | | | | | - Dan M. Roden
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | | | | | - Sojin Youn Wass
- Cleveland Clinic, Cleveland, OH
- University Hospitals Cleveland Medical Center, Cleveland, OH
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Scalia P, Barr PJ, O'Neill C, Crealey GE, Bagley PJ, Blunt HB, Elwyn G. Does the use of patient decision aids lead to cost savings? a systematic review. BMJ Open 2020; 10:e036834. [PMID: 33199416 PMCID: PMC7670951 DOI: 10.1136/bmjopen-2020-036834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To update a previous systematic review to determine if patient decision aid (PDA) interventions generate savings in healthcare settings, and if so, from which perspective (ie, patient, organisation providing care, society). DESIGN Systematic review. DATA SOURCES MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Embase, Campbell Collaboration Library, EconLit, Business Source Complete, Centre for Reviews and Dissemination: NHS Economic Evaluations Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) from 15 March 2013 to 25 January 2019. The references of studies that met the eligibility criteria and any publications related to conference abstracts or registered clinical trials were reviewed to increase the sensitivity of the search. ELIGIBILITY CRITERIA Full and partial economic evaluations with an experimental, quasi-experimental or randomised controlled design were included. The intervention had to satisfy the pre-determined minimum conditions necessary to be defined as a PDA, and (for full evaluations) provide details on the comparator used. DATA EXTRACTION AND SYNTHESIS All study outcomes and economic data were extracted. The reporting and quality of the economic analyses were independently assessed by two health economists. RESULTS Of 5066 studies, 22 studies were included, including the 8 studies from the previous review. Twelve studies reported cost-savings (range=US$10 to US$81 156; US dollars in 2020), primarily from the organisational or health system perspective, and 10 studies did not. However, due to the quality of the economic analyses, and the related issues with the interpretative validity of results it would be inappropriate to say that PDAs will generate savings, from any perspective. CONCLUSIONS It is unclear whether PDAs will generate savings. Greater consensus on what constitutes a PDA and the need to compare them against usual care over a sufficient time horizon to allow valid assessment of costs and outcomes is required. PROSPERO REGISTRATION NUMBER CRD42019118457.
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Affiliation(s)
- Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Ciaran O'Neill
- Centre for Public Health, Queen's University Belfast, Belfast, Belfast, UK
| | | | - Pamela J Bagley
- Dartmouth College Biomedical Libraries, Hanover, New Hampshire, USA
| | - Heather B Blunt
- Dartmouth College Biomedical Libraries, Hanover, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
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10
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Thiessen M, Sinclair S, Tang PA, Raffin Bouchal S. Information Access and Use by Patients With Cancer and Their Friends and Family: Development of a Grounded Theory. J Med Internet Res 2020; 22:e20510. [PMID: 33118940 PMCID: PMC7661235 DOI: 10.2196/20510] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/29/2020] [Accepted: 09/17/2020] [Indexed: 12/17/2022] Open
Abstract
Background Information has been identified as a commonly unmet supportive care need for those living with cancer (ie, patients and their friends and family). The information needed to help individuals plan their lives around the consequences of cancer, such as the receipt of health care, is an example of an important informational need. A suitable theory to guide the development of interventions designed to meet this informational need has not been identified by the authors. Objective The aim of this study is to generate a grounded theory capable of guiding the development of interventions designed to assist those living with cancer in meeting their informational needs. Methods Classic grounded theory was used to analyze data collected through digitally recorded one-on-one audio interviews with 31 patients with cancer and 29 friends and family members. These interviews focused on how the participants had accessed and used information to plan their lives and what barriers they faced in obtaining and using this information. Results The theory that emerged consisted of 4 variables: personal projects, cancer as a source of disruption to personal projects, information as the process of accessing and interpreting cancer-related data (CRD) to inform action, and CRD quality as defined by accessibility, credibility, applicability, and framing. CRD quality as a moderator of personal project disruption by cancer is the core concept of this theory. Conclusions Informational resources providing accessible, credible, applicable, and positively framed CRD are likely key to meeting the information needs of those affected by cancer. Web-based informational resources delivering high-quality CRD focused on assisting individuals living with cancer in maintaining and planning their personal projects are predicted to improve quality of life. Research is needed to develop and integrate resources informed by this theoretical framework into clinical practice.
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Affiliation(s)
- Maclean Thiessen
- Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada.,Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Shane Sinclair
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada.,Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Patricia A Tang
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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11
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Ankolekar A, Dekker A, Fijten R, Berlanga A. The Benefits and Challenges of Using Patient Decision Aids to Support Shared Decision Making in Health Care. JCO Clin Cancer Inform 2019; 2:1-10. [PMID: 30652607 DOI: 10.1200/cci.18.00013] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Shared decision making (SDM) and patient-centered care require patients to actively participate in the decision-making process. Yet with the increasing number and complexity of cancer treatment options, it can be a challenge for patients to evaluate clinical information and make risk-benefit trade-offs to choose the most appropriate treatment. Clinicians face time constraints and communication challenges, which can further hamper the SDM process. In this article, we review patient decision aids (PDAs) as a means of supporting SDM by presenting clinical information and risk data to patients in a format that is accessible and easy to understand. We outline the benefits and limitations of PDAs as well as the challenges in their development, such as a lengthy and complex development process and implementation obstacles. Lastly, we discuss future trends and how change on multiple levels-PDA developers, clinicians, hospital administrators, and health care insurers-can support the use of PDAs and consequently SDM. Through this multipronged approach, patients can be empowered to take an active role in their health and choose treatments that are in line with their values.
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Affiliation(s)
- Anshu Ankolekar
- Anshu Ankolekar, Andre Dekker, and Rianne Fijten, Maastricht University Medical Centre, Maastricht; and Adriana Berlanga, Maastricht University, Maastricht, the Netherlands
| | - Andre Dekker
- Anshu Ankolekar, Andre Dekker, and Rianne Fijten, Maastricht University Medical Centre, Maastricht; and Adriana Berlanga, Maastricht University, Maastricht, the Netherlands
| | - Rianne Fijten
- Anshu Ankolekar, Andre Dekker, and Rianne Fijten, Maastricht University Medical Centre, Maastricht; and Adriana Berlanga, Maastricht University, Maastricht, the Netherlands
| | - Adriana Berlanga
- Anshu Ankolekar, Andre Dekker, and Rianne Fijten, Maastricht University Medical Centre, Maastricht; and Adriana Berlanga, Maastricht University, Maastricht, the Netherlands
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12
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Abstract
Decision aids, sometimes known as decision-support tools, are increasingly used to help patients to understand treatment options and to reach an informed decision consistent with their own values, yet methods for their economic evaluation have received limited attention. This is at odds with the increasingly rigorous methods being applied to assess the cost effectiveness of other health technologies. This paper reviews current approaches to evaluating decision aids and proposes a new method for assessing their benefits relative to other interventions in a resource-constrained health system that seeks to improve health, equity and patient satisfaction. Current evaluation frameworks are found to be unsuitable for the economic evaluation of decision aids since their objectives are broader than health maximisation. Decision aids may generate significant non-health benefits such as improved patient knowledge and satisfaction, which cannot be assessed using cost-utility analysis. A stated-preference consultation time trade-off (CTTO) is proposed in which a proportion of hypothetical physician consultation is traded for use of the decision aid. A decision aid provides information for a patient to make an informed choice and therefore may be considered to be a substitute for physician time. The CTTO can be reported in consultation minutes or converted to monetary units using the cost of physician time. These values may be used, alongside the implementation cost, for economic evaluation.
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Affiliation(s)
- Thomas Butt
- National School of Development, Peking University, Beijing, China.
- Institute of Ophthalmology, University College London, London, UK.
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13
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Enhancing Equitable Access to Assistive Technologies in Canada: Insights from Citizens and Stakeholders. Can J Aging 2019; 39:69-88. [DOI: 10.1017/s0714980819000187] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
RÉSUMÉLes besoins en technologies d’assistance augmentent au Canada, mais l’accès à ces technologies est inégal et fragmentaire, ce qui ferait en sorte que des besoins demeureraient non comblés. Cette étude visait à identifier les valeurs et préférences des citoyens concernant les moyens à utiliser pour favoriser un accès équitable aux technologies d’assistance. Elle visait également à impliquer les décideurs politiques, les parties prenantes et les chercheurs dans des discussions afin d’élaborer des actions dans ce domaine. Au printemps 2017, nous avons organisé trois panels de citoyens et un dialogue avec les parties prenantes. Les principales conclusions des panels ont été incluses dans une synthèse qui a été partagée avec les participants du dialogue. Trente-sept citoyens ont participé aux panels et ont souligné l’importance de l’accès à de l’information fiable, d’un accès équitable aux technologies d’assistance (et ce, quelle que soit la capacité de payer), et de la collaboration. Les vingt-deux participants au dialogue ont fait valoir la nécessité d’un cadre d’orientation pour appuyer l’évolution des pratiques dans l’ensemble au pays. Le cadre d’orientation proposé combinerait des politiques et programmes simplifiés incluant la collecte et l’évaluation de données robustes pour appuyer l’innovation et l’imputabilité à travers le pays.
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14
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Squires JE, Stacey D, Coughlin M, Greenough M, Roberts A, Dorrance K, Clemons M, Caudrelier JM, Graham ID, Zhang J, Varin MD, Arnaout A. Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study. Curr Oncol 2019; 26:137-148. [PMID: 31043816 PMCID: PMC6476460 DOI: 10.3747/co.26.4689] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm. Methods A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions. Results The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da. Conclusions The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.
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Affiliation(s)
- J E Squires
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - D Stacey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - M Coughlin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - M Greenough
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - A Roberts
- Breast Surgical Oncology Unit, The Ottawa Hospital, Ottawa, ON
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - K Dorrance
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - M Clemons
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Medicine, University of Ottawa, Ottawa, ON
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
| | - J M Caudrelier
- Department of Radiation Medicine, The Ottawa Hospital, Ottawa, ON
| | - I D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
| | - J Zhang
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, ON
- Department of Plastic Surgery, The Ottawa Hospital, Ottawa, ON
| | - M Demery Varin
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - A Arnaout
- Breast Surgical Oncology Unit, The Ottawa Hospital, Ottawa, ON
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, ON
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15
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Gualano MR, Bert F, Passi S, Stillo M, Brescia V, Scaioli G, Thomas R, Voglino G, Minniti D, Boraso F, Siliquini R. Could shared decision making affect staying in hospital? A cross-sectional pilot study. BMC Health Serv Res 2019; 19:174. [PMID: 30885180 PMCID: PMC6423869 DOI: 10.1186/s12913-019-4002-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/11/2019] [Indexed: 01/09/2023] Open
Abstract
Background Shared Decision Making (SDM) is an approach where clinicians and patients share the best available evidence to make decision and where patients opinions are considered. This approach provides benefits for patients, clinicians and health care system. The aim of the present study is to investigate the patients’ perception of their participation in treatment choices and to identify the possible influences of variables in decision aids and therapeutic choices. Furthermore the present study evaluates the impact of SDM on the length of hospital stay and the health expenditure in Piemonte, an Italian region. Methods A cross-sectional study was performed in 2016. The patients were selected after hospitalization to clinical and surgical units at the Rivoli and Susa Hospital. Data were collected through the questionnaire and the Hospital Discharge Registers. STROBE guidelines for observational studies were used. A descriptive analysis was conducted. Frequencies and percentages of the categorical variables were reported. Statistical analyses were performed using t-test, chi-square test and Mann-Whitney test. Results The final sample was made of 174 subjects. More than half of the sample reported a SDM approach. Female gender (p = 0.027) and lower age (p = 0.047) are associated with an increased possibility to report SDM. Receiving “good” or “excellent” information, having their own request fulfilled and their opinions took into account by healthcare professionals, were all found to be predictors for an approach recognized as SDM (p ≤ 0.05). The perception that healthcare professionals spent a proper amount of time with the patients and used an understendable language are factors increase the chance of a “shared” decision process (p ≤ 0.05). The patients trust in the information given by the healthcare professional is not affecting their perception about the decision making process (P = 0.195). No significant difference where recorded in length of stay and hospital expenditure. Conclusions The data show the role played by different dimension of the patients-clinician relationship and that the strongest determinant of a perceived shared decision making approach are healthcare professional-depending.
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Affiliation(s)
- M R Gualano
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy
| | - F Bert
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy.,AOU Città della Salute e della Scienza, Torino, Italy
| | - S Passi
- Local Health Unit, ASL TO 3, Piedmont, Italy
| | - M Stillo
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy
| | - V Brescia
- Department of Management, University of Torino, Torino, Italy
| | - G Scaioli
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy
| | - R Thomas
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy
| | - G Voglino
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy.
| | - D Minniti
- Local Health Unit, ASL TO 3, Piedmont, Italy
| | - F Boraso
- Local Health Unit, ASL TO 3, Piedmont, Italy
| | - R Siliquini
- Department of Public Health Sciences, University of Turin, Via Santena 5 bis, 10126, Turin, Italy.,AOU Città della Salute e della Scienza, Torino, Italy
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16
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Shared Decision Making in Psoriasis: A Systematic Review of Quantitative and Qualitative Studies. Am J Clin Dermatol 2019; 20:13-29. [PMID: 30324563 DOI: 10.1007/s40257-018-0390-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Patients with psoriasis face numerous treatment and self-management decisions. Shared decision making is a novel approach where patients' preferences and values are considered in cooperation with healthcare professionals before making treatment decisions. OBJECTIVE The objective of this systematic review was to explore what is illuminated in psoriasis research regarding shared decision making, and to estimate the effects of shared decision-making interventions in this context. METHODS Qualitative, quantitative, and mixed-methods studies were eligible for inclusion. We searched six electronic databases up to January 2018. Two reviewers independently applied inclusion and quality criteria. The SPIDER framework was used to identify eligibility criteria for study inclusion. Narrative and thematic syntheses were utilized to identify prominent themes emerging from the data. RESULTS A total of 23 studies were included in the review. Of these, we included 18 studies (19 papers) to describe what was illuminated with regard to shared decision making in psoriasis research. Four major themes emerged: interpersonal communication; exchange of competence and knowledge; different world view; and involvement and preference, organized under two analytical themes; "Co-creation of decisions" and "Organization of treatment and treatment needs". For shared decision-making effects, we included four controlled studies. These varied in scope and interventional length and showed limited use of shared decision making-specific outcome measures, reflecting the early stage of the literature. Because of study heterogeneity, a meta-synthesis was not justified. CONCLUSIONS There appears to be a need to strengthen the relationship between medical doctors and patients with psoriasis. The evident lack of knowledge about each other's competence and the lack of self-efficacy for both patients and providers challenges the basic principles of shared decision making. The effects of shared decision making in psoriasis are inconclusive, and more research appears necessary to determine the possible benefits of shared decision-making interventions.
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17
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Geerse OP, Stegmann ME, Kerstjens HAM, Hiltermann TJN, Bakitas M, Zimmermann C, Deal AM, Brandenbarg D, Berger MY, Berendsen AJ. Effects of Shared Decision Making on Distress and Health Care Utilization Among Patients With Lung Cancer: A Systematic Review. J Pain Symptom Manage 2018; 56:975-987.e5. [PMID: 30145213 DOI: 10.1016/j.jpainsymman.2018.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT Lung cancer is associated with significant distress, poor quality of life, and a median prognosis of less than one year. Benefits of shared decision making (SDM) have been described for multiple diseases, either by the use of decisions aids or as part of supportive care interventions. OBJECTIVES The objective of this study was to summarize the effects of interventions facilitating SDM on distress and health care utilization among patients with lung cancer. METHODS We performed a systematic literature search in the CINAHL, Cochrane, EMBASE, MEDLINE, and PsychINFO databases. Studies were eligible when conducted in a population of patients with lung cancer, evaluated the effects of an intervention that facilitated SDM, and measured distress and/or health care utilization as outcomes. RESULTS A total of 12 studies, detailed in 13 publications, were included: nine randomized trials and three retrospective cohort studies. All studies reported on a supportive care intervention facilitating SDM as part of their intervention. Eight studies described effects on distress, and eight studies measured effects on health care utilization. No effect was found in studies measuring generic distress. Positive effects, in favor of the intervention groups, were observed in studies using anxiety-specific measures (n = 1) or depression-specific measures (n = 3). Evidence for reductions in health care utilization was found in five studies. CONCLUSION Although not supported by all studies, our findings suggest that facilitating SDM in the context of lung cancer may lead to improved emotional outcomes and less aggressive therapies. Future studies, explicitly studying the effects of SDM by using decision aids, are needed to better elucidate potential benefits.
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Affiliation(s)
- Olaf P Geerse
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Mariken E Stegmann
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijo Jeroen N Hiltermann
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre and Department of Medicine, University of Toronto, Toronto, Canada
| | - Allison M Deal
- Department of Biostatistics and Clinical Data Management Core, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Daan Brandenbarg
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annette J Berendsen
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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18
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Ogink PT, Teunis T, van Wulfften Palthe O, Sepucha K, Bono CM, Schwab JH, Cha TD. Variation in costs among surgeons for lumbar spinal stenosis. Spine J 2018; 18:1584-1591. [PMID: 29496622 DOI: 10.1016/j.spinee.2018.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/22/2018] [Accepted: 02/13/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar spinal stenosis is a common condition in the elderly for which costs vary substantially by region. Comparing differences between surgeons from a single institution, thereby omitting regional variation, could aid in identifying factors associated with higher costs and individual drivers of costs. The use of decision aids (DAs) has been suggested as one of the possible tools for diminishing costs and cost variation. PURPOSE (1) To determine factors associated with higher costs for treatment of spinal stenosis in the first year after diagnosis in a single institution; (2) to find individual drivers of costs for providers with higher costs; and (3) to determine if the use of DAs can decrease costs and cost variability. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE A total of 10,858 patients in 18 different practices diagnosed with lumbar spinal stenosis between January 2003 and July 2015 in three associated hospitals of a single institution. OUTCOME MEASURES Mean cost for a patient per provider in US dollars within 1 year after diagnosis of lumbar spinal stenosis. METHODS We collected all diagnostic testing, office visits, injections, surgery, and occupational or physical therapy related to lumbar spinal stenosis within 1 year after initial diagnosis. We used multivariable linear regression to determine independent predictors for costs. Providers were grouped in tiers based on mean total costs per patient to find drivers of costs. To assess the DAs effect on costs and cost variability, we matched DA patients one-to-one with non-DA patients. RESULTS Male gender (β 0.10, 95% confidence interval [CI] 0.05-0.15, p<.001), seeing an additional provider (β 0.77, 95% CI 0.69-0.86, p<.001), and having an additional spine diagnosis (β 0.79, 95% CI 0.74-0.84, p<.001) were associated with higher costs. Providers in the high cost tier had more office visits (p<.001), more imaging procedures (p<.001), less occupational or physical therapy (p=.002), and less surgery (p=.001) compared with the middle tier. Eighty-two patients (0.76%) received a DA as part of their care; there was no statistically significant difference between the DA group and the matched group in costs (p=.975). CONCLUSIONS Male gender, seeing an additional provider, and having an additional spine diagnosis were independently associated with higher costs. The main targets for cost reduction we found are imaging procedures and number of office visits. Decision aids were not found to affect cost.
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Affiliation(s)
- Paul T Ogink
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Teun Teunis
- Department of Plastic Surgery, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Olivier van Wulfften Palthe
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Karen Sepucha
- Division of General Internal Medicine, Health Decision Sciences Center, Massachusetts General Hospital-Harvard Medical School, 50 Staniford St, Boston, MA 02114, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Brigham and Women's Hospital-Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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19
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Elwyn G, Burstin H, Barry MJ, Corry MP, Durand MA, Lessler D, Saigal C. A proposal for the development of national certification standards for patient decision aids in the US. Health Policy 2018; 122:703-706. [DOI: 10.1016/j.healthpol.2018.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 02/09/2018] [Accepted: 04/20/2018] [Indexed: 11/28/2022]
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20
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Return on Investment for a Payer-Provider Partnership to Improve Care Management of Employees and Early Retirees. J Occup Environ Med 2018; 60:241-247. [PMID: 29370010 DOI: 10.1097/jom.0000000000001279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A large employer partnered with local health care providers to pilot test an intensive nurse care manager program for employees and retirees. We evaluated its impact on health care utilization and costs. METHODS A database was developed containing 2011 to 2015 health care enrollment and claims data for 2914 patients linked to their nurse care manager data. We used a difference-in-difference design to compare health care costs and utilization of members recruited for the pilot program and a propensity-score-matched comparison group. RESULTS We found statistically significant reductions in doctors' office visits and prescription drug costs. A return-on-investment analysis determined that the program saved $0.83 for every dollar spent over the 2-year pilot study period. CONCLUSIONS Employer-driven care management programs can succeed at reducing utilization, although they may not achieve cost neutrality in the short run.
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21
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Van der Wees PJ, Wammes JJG, Jeurissen PPT, Westert GP. Stewardship of primary care physicians to contain cost in health care: an international cross-sectional survey. Fam Pract 2017; 34:717-722. [PMID: 28968666 DOI: 10.1093/fampra/cmx077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Physician stewardship towards cost control is potentially important in enhancing the financial sustainability of health care systems. OBJECTIVE Aim of this study was to identify the level of stewardship of cost containment of primary care physicians (PCPs) and to assess the associations between stewardship and characteristics of PCPs and health care systems. METHODS Secondary analysis of data from a cross-sectional survey among 10 countries: Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, UK and USA. Participants were a random sample of 33312 PCPs with 11547 responses (34.7%). Outcome measure was a stewardship scale addressing cost-awareness and cost-consideration. RESULTS Across countries, 41.6% and 45.7% of the PCPs responded that they often were aware of treatment costs and considered cost, respectively. Female PCPs were less aware of costs (OR: 0.75; 95% CI: 0.69-0.81) and considered costs less frequently in making treatment decisions (OR: 0.82; 95% CI: 0.76-0.89). Older PCPs were more aware of the costs than younger PCPs for all age categories compared to those <35 years (P < 0.001). PCPs older than 65 years (OR: 0.64; 95% CI: 0.54-0.78) and 55-64 years (OR: 0.84; 95%CI: 0.73-0.97) were less likely to consider costs than the youngest age group. Cost-consideration of PCPs residing in countries with a single payer system was lower (OR: 0.58; 95% CI 0.35-0.95) than their colleagues in multiple payer systems. CONCLUSION PCPs show moderate stewardship of health care resources with large intercountry differences. Cost-awareness may not be a necessary precondition for cost-consideration, and policies aimed at raising cost-consideration may be more important.
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Affiliation(s)
- Philip J Van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Joost J G Wammes
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Patrick P T Jeurissen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
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22
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Abstract
BACKGROUND Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment. METHODS 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment. FINDINGS The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs. CONCLUSION From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.
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Lyu H, Xu T, Brotman D, Mayer-Blackwell B, Cooper M, Daniel M, Wick EC, Saini V, Brownlee S, Makary MA. Overtreatment in the United States. PLoS One 2017; 12:e0181970. [PMID: 28877170 PMCID: PMC5587107 DOI: 10.1371/journal.pone.0181970] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/10/2017] [Indexed: 01/13/2023] Open
Abstract
Background Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment. Methods 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment. Findings The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs. Conclusion From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.
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Affiliation(s)
- Heather Lyu
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Tim Xu
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel Brotman
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Brandan Mayer-Blackwell
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michol Cooper
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michael Daniel
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elizabeth C. Wick
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Vikas Saini
- The Lown Institute, Boston, Massachusetts, United States of America
| | - Shannon Brownlee
- The Lown Institute, Boston, Massachusetts, United States of America
| | - Martin A. Makary
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Zandstra D, Busser J, Aarts J, Nieboer T. Interventions to support shared decision-making for women with heavy menstrual bleeding: A systematic review. Eur J Obstet Gynecol Reprod Biol 2017; 211:156-163. [DOI: 10.1016/j.ejogrb.2017.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 02/26/2017] [Indexed: 10/20/2022]
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Blair L, Légaré F. Is Shared Decision Making a Utopian Dream or an Achievable Goal? PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 8:471-6. [PMID: 25680338 DOI: 10.1007/s40271-015-0117-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The idea of shared decision making (SDM) between patient and physician grew out of a generalized challenge to traditional social hierarchies that occurred in the middle of the last century. Governments have espoused SDM, thousands of articles about it have been published, and evidence has shown that it improves some of the healthcare processes as well as patient outcomes. Yet it has not been widely adopted. From their cross-disciplinary perspective (practical theology and clinical medicine), the authors locate this reluctance in the unfolding of scientific paradigm shifts, summarize the perceived risks and benefits of SDM and the evidence for each, and suggest practical, achievable approaches for clinicians. Finally, they explore some important emerging territories for SDM.
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Affiliation(s)
- Louisa Blair
- Department of Practical Theology, Faculté de théologie et de sciences religieuses, Université Laval, Pavillon Félix-Antoine-Savard, 2325, rue des Bibliothèques, Quebec, QC, G1V 0A6, Canada
| | - France Légaré
- Canada Research Chair in Implementation of Shared Decision Making in Primary Care, Université Laval, Quebec City, Canada. .,CHU de Quebec Research Centre, Hôpital Saint-François d'Assise, 10, rue de l'Espinay, Quebec, QC, G1L 3L5, Canada.
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Légaré F, Hébert J, Goh L, Lewis KB, Leiva Portocarrero ME, Robitaille H, Stacey D. Do choosing wisely tools meet criteria for patient decision aids? A descriptive analysis of patient materials. BMJ Open 2016; 6:e011918. [PMID: 27566638 PMCID: PMC5013503 DOI: 10.1136/bmjopen-2016-011918] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Choosing Wisely is a remarkable physician-led campaign to reduce unnecessary or harmful health services. Some of the literature identifies Choosing Wisely as a shared decision-making approach. We evaluated the patient materials developed by Choosing Wisely Canada to determine whether they meet the criteria for shared decision-making tools known as patient decision aids. DESIGN Descriptive analysis of all Choosing Wisely Canada patient materials. DATA SOURCE In May 2015, we selected all Choosing Wisely Canada patient materials from its official website. MAIN OUTCOMES AND MEASURES Four team members independently extracted characteristics of the English materials using the International Patient Decision Aid Standards (IPDAS) modified 16-item minimum criteria for qualifying and certifying patient decision aids. The research team discussed discrepancies between data extractors and reached a consensus. Descriptive analysis was conducted. RESULTS Of the 24 patient materials assessed, 12 were about treatments, 11 were about screening and 1 was about prevention. The median score for patient materials using IPDAS criteria was 10/16 (range: 8-11) for screening topics and 6/12 (range: 6-9) for prevention and treatment topics. Commonly missed criteria were stating the decision (21/24 did not), providing balanced information on option benefits/harms (24/24 did not), citing evidence (24/24 did not) and updating policy (24/24 did not). Out of 24 patient materials, only 2 met the 6 IPDAS criteria to qualify as patient decision aids, and neither of these 2 met the 6 certifying criteria. CONCLUSIONS Patient materials developed by Choosing Wisely Canada do not meet the IPDAS minimal qualifying or certifying criteria for patient decision aids. Modifications to the Choosing Wisely Canada patient materials would help to ensure that they qualify as patient decision aids and thus as more effective shared decision-making tools.
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Affiliation(s)
- France Légaré
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Research Axis of Population Health and Practice-Changing Research, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Pavillon Ferdinand-Vandry, Quebec City, Quebec, Canada
| | - Jessica Hébert
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Research Axis of Population Health and Practice-Changing Research, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec City, Quebec, Canada
| | - Larissa Goh
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Research Axis of Population Health and Practice-Changing Research, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec City, Quebec, Canada
| | - Krystina B Lewis
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Maria Ester Leiva Portocarrero
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Research Axis of Population Health and Practice-Changing Research, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec City, Quebec, Canada
| | - Hubert Robitaille
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Research Axis of Population Health and Practice-Changing Research, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec City, Quebec, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Elwyn G, Frosch DL, Kobrin S. Implementing shared decision-making: consider all the consequences. Implement Sci 2016; 11:114. [PMID: 27502770 PMCID: PMC4977650 DOI: 10.1186/s13012-016-0480-9] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 08/01/2016] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The ethical argument that shared decision-making is "the right" thing to do, however laudable, is unlikely to change how healthcare is organized, just as evidence alone will be an insufficient factor: practice change is governed by factors such as cost, profit margin, quality, and efficiency. It is helpful, therefore, when evaluating new approaches such as shared decision-making to conceptualize potential consequences in a way that is broad, long-term, and as relevant as possible to multiple stakeholders. Yet, so far, evaluation metrics for shared decision-making have been mostly focused on short-term outcomes, such as cognitive or affective consequences in patients. The goal of this article is to hypothesize a wider set of consequences, that apply over an extended time horizon, and include outcomes at interactional, team, organizational and system levels, and to call for future research to study these possible consequences. MAIN ARGUMENT To date, many more studies have evaluated patient decision aids rather than other approaches to shared decision-making, and the outcomes measured have typically been focused on short-term cognitive and affective outcomes, for example knowledge and decisional conflict. From a clinicians perspective, the shared decision-making process could be viewed as either intrinsically rewarding and protective, or burdensome and impractical, yet studies have not focused on the impact on professionals, either positive or negative. At interactional levels, group, team, and microsystem, the potential long-term consequences could include the development of a culture where deliberation and collaboration are regarded as guiding principles, where patients are coached to assess the value of interventions, to trade-off benefits versus harms, and assess their burdens-in short, to new social norms in the clinical workplace. At organizational levels, consistent shared decision-making might boost patient experience evaluations and lead to fewer complaints and legal challenges. In the long-term, shared decision-making might lead to changes in resource utilization, perhaps to reductions in cost, and to modification of workforce composition. Despite the gradual shift to value-based payment, some organizations, motivated by continued income derived from achieving high volumes of procedures and contacts, will see this as a negative consequence. CONCLUSION We suggest that a broader conceptualization and measurement of shared decision-making would provide a more substantive evidence base to guide implementation. We outline a framework which illustrates a hypothesized set of proximal, distal, and distant consequences that might occur if collaboration and deliberation could be achieved routinely, proposing that well-informed preference-based patient decisions might lead to safer, more cost-effective healthcare, which in turn might result in reduced utilization rates and improved health outcomes.
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Affiliation(s)
- Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, 37 Dewey Field Road, Hanover, NH, 03755, USA.
| | - Dominick L Frosch
- Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA.,Department of Medicine, University of California, Los Angeles, CA, 90024, USA
| | - Sarah Kobrin
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
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Hogden A, Greenfield D, Caga J, Cai X. Development of patient decision support tools for motor neuron disease using stakeholder consultation: a study protocol. BMJ Open 2016; 6:e010532. [PMID: 27053272 PMCID: PMC4823454 DOI: 10.1136/bmjopen-2015-010532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Motor neuron disease (MND) is a terminal, progressive, multisystem disorder. Well-timed decisions are key to effective symptom management. To date, there are few published decision support tools, also known as decision aids, to guide patients in making ongoing choices for symptom management and quality of life. This protocol is to develop and validate decision support tools for patients and families to use in conjunction with health professionals in MND multidisciplinary care. The tools will inform patients and families of the benefits and risks of each option, as well as the consequences of accepting or declining treatment. METHODS AND ANALYSIS The study is being conducted from June 2015 to May 2016, using a modified Delphi process. A 2-stage, 7-step process will be used to develop the tools, based on existing literature and stakeholder feedback. The first stage will be to develop the decision support tools, while the second stage will be to validate both the tools and the process used to develop them. Participants will form expert panels, to provide feedback on which the development and validation of the tools will be based. Participants will be drawn from patients with MND, family carers and health professionals, support association workers, peak body representatives, and MND and patient decision-making researchers. ETHICS AND DISSEMINATION Ethical approval for the study has been granted by Macquarie University Human Research Ethics Committee (HREC), approval number 5201500658. Knowledge translation will be conducted via publications, seminar and conference presentations to patients and families, health professionals and researchers.
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Affiliation(s)
- Anne Hogden
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - David Greenfield
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jashelle Caga
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Xiongcai Cai
- School of Computer Science and Engineering, University of New South Wales, Sydney, New South Wales, Australia
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Dambha-Miller H, Cooper AJM, Simmons RK, Kinmonth AL, Griffin SJ. Patient-centred care, health behaviours and cardiovascular risk factor levels in people with recently diagnosed type 2 diabetes: 5-year follow-up of the ADDITION-Plus trial cohort. BMJ Open 2016; 6:e008931. [PMID: 26739725 PMCID: PMC4716169 DOI: 10.1136/bmjopen-2015-008931] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To examine the association between the experience of patient-centred care (PCC), health behaviours and cardiovascular disease (CVD) risk factor levels among people with type 2 diabetes. DESIGN Population-based prospective cohort study. SETTING 34 general practices in East Anglia, UK, delivering organised diabetes care. PARTICIPANTS 478 patients recently diagnosed with type 2 diabetes aged between 40 and 69 years enrolled in the ADDITION-Plus trial. MAIN OUTCOME MEASURES Self-reported and objectively measured health behaviours (diet, physical activity, smoking status), CVD risk factor levels (blood pressure, lipid levels, glycated haemoglobin, body mass index, waist circumference) and modelled 10-year CVD risk. RESULTS Better experiences of PCC early in the course of living with diabetes were not associated with meaningful differences in self-reported physical activity levels including total activity energy expenditure (β-coefficient: 0.080 MET h/day (95% CI 0.017 to 0.143; p=0.01)), moderate-to-vigorous physical activity (β-coefficient: 5.328 min/day (95% CI 0.796 to 9.859; p=0.01)) and reduced sedentary time (β-coefficient: -1.633 min/day (95% CI -2.897 to -0.368; p=0.01)). PCC was not associated with clinically meaningful differences in levels of high-density lipoprotein cholesterol (β-coefficient: 0.002 mmol/L (95% CI 0.001 to 0.004; p=0.03)), systolic blood pressure (β-coefficient: -0.561 mm Hg (95% CI -0.653 to -0.468; p=0.01)) or diastolic blood pressure (β-coefficient: -0.565 mm Hg (95% CI -0.654 to -0.476; p=0.01)). Over an extended follow-up of 5 years, we observed no clear evidence that PCC was associated with self-reported, clinical or biochemical outcomes, except for waist circumference (β-coefficient: 0.085 cm (95% CI 0.015 to 0.155; p=0.02)). CONCLUSIONS We found little evidence that experience of PCC early in the course of diabetes was associated with clinically important changes in health-related behaviours or CVD risk factors. TRIAL REGISTRATION NUMBER ISRCTN99175498; Post-results.
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Affiliation(s)
- Hajira Dambha-Miller
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Andrew J M Cooper
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Rebecca K Simmons
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Ann Louise Kinmonth
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
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Cost effectiveness of a web-based decision aid for parents deciding about MMR vaccination: a three-arm cluster randomised controlled trial in primary care. Br J Gen Pract 2015; 64:e493-9. [PMID: 25071062 DOI: 10.3399/bjgp14x680977] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Levels of measles in England and Wales are at their highest for 18 years, and strategies targeting the different groups of parents who do not vaccinate their children continue to be needed. Decision aids for decisions regarding childhood immunisation appear to be effective in achieving an increase in vaccine uptake but their cost effectiveness is unknown. AIM To assess the cost effectiveness of a web-based decision aid to increase uptake of the MMR vaccine. DESIGN AND SETTING Economic evaluation conducted alongside a cluster randomised controlled trial using urban GP practices in the north of England. METHOD Fifty GP practices in the north of England were randomised to one of three trial arms: decision aid, leaflet, usual practice. A total of 220 first-time parents (child aged 3-12 months) were recruited. Parents self-reported their contacts with the NHS and other previous/expected resource utilisation; associated costs were calculated. Vaccine-uptake data were collected from GP practices. A cost-effectiveness analysis was undertaken and provided the incremental cost per first-vaccine uptake. Multiple imputation was used to account for missing data and findings were adjusted for baseline differences in parents' levels of decisional conflict regarding MMR vaccination. RESULTS Of the 220 first-time parents recruited to the study, 179 completed the baseline and post-intervention questionnaires. MMR uptake was highest for those receiving the decision aid (42 out of 42, 100%) versus usual practice (61 out of 62, 98%) and leaflet arm (69 out of 75, 92%), and was associated with lower cost (-£9.20 versus usual practice and -£7.17 versus leaflet). CONCLUSION The decision aid has a high chance of being cost effective, regardless of the value placed on obtaining additional vaccinations. It also appears to offer an efficient means of decision support for parents.
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Stiggelbout AM, Pieterse AH, De Haes JCJM. Shared decision making: Concepts, evidence, and practice. PATIENT EDUCATION AND COUNSELING 2015; 98:1172-1179. [PMID: 26215573 DOI: 10.1016/j.pec.2015.06.022] [Citation(s) in RCA: 479] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/27/2015] [Accepted: 06/29/2015] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Shared decision-making (SDM) is advocated as the model for decision-making in preference-sensitive decisions. In this paper we sketch the history of the concept of SDM, evidence on the occurrence of the steps in daily practice, and provide a clinical audience with communication strategies to support the steps involved. Finally, we discuss ways to improve the implementation of SDM. RESULTS The plea for SDM originated almost simultaneously in medical ethics and health services research. Four steps can be distinguished: (1) the professional informs the patient that a decision is to be made and that the patient's opinion is important; (2) the professional explains the options and their pros and cons; (3) the professional and the patient discuss the patient's preferences and the professional supports the patient in deliberation; (4) the professional and patient discuss the patient's wish to make the decision, they make or defer the decision, and discuss follow-up. In practice these steps are seen to occur to a limited extent. DISCUSSION Knowledge and awareness among both professionals and patients as well as tools and skills training are needed for SDM to become widely implemented. PRACTICE IMPLICATIONS Professionals may use the steps and accompanying communication strategies to implement SDM.
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Affiliation(s)
- A M Stiggelbout
- Department of Medical Decision Making/Quality of Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - A H Pieterse
- Department of Medical Decision Making/Quality of Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J C J M De Haes
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
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van der Eijk M, Faber MJ, Post B, Okun MS, Schmidt P, Munneke M, Bloem BR. Capturing patients' experiences to change Parkinson's disease care delivery: a multicenter study. J Neurol 2015; 262:2528-38. [PMID: 26292793 PMCID: PMC4639577 DOI: 10.1007/s00415-015-7877-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/31/2015] [Accepted: 08/01/2015] [Indexed: 11/30/2022]
Abstract
Capturing patients’ perspectives has become an essential part of a quality of care assessment. The patient centeredness questionnaire for PD (PCQ-PD) has been validated in The Netherlands as an instrument to measure patients’ experiences. This study aims to assess the level of patient centeredness in North American Parkinson centers and to demonstrate the PCQ-PD’s potential as a quality improvement instrument. 20 Parkinson Centers of Excellence participated in a multicenter study. Each center asked 50 consecutive patients to complete the questionnaire. Data analyses included calculating case mix-adjusted scores for overall patient centeredness (scoring range 0–3), six subscales (0–3), and quality improvement (0–9). Each center received a feedback report on their performance. The PCQ-PD was completed by 972 PD patients (median 50 per center, range 37–58). Significant differences between centers were found for all subscales, except for emotional support (p < 0.05). The information subscale (mean 1.62 SD 0.62) and collaboration subscale (mean 2.03 SD 0.58) received the lowest experience ratings. 14 centers (88 %) who returned the evaluation survey claimed that patient experience scores could help to improve the quality of care. Nine centers (56 %) utilized the feedback to change specific elements of their care delivery process. PD patients are under-informed about critical care issues and experience a lack of collaboration between healthcare professionals. Feedback on patients’ experiences facilitated Parkinson centers to improve their delivery of care. These findings create a basis for collecting patients’ experiences in a repetitive fashion, intertwined with existing quality of care registries.
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Affiliation(s)
- Martijn van der Eijk
- Department of Neurology, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marjan J Faber
- Department of Neurology, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Post
- Department of Neurology (935), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael S Okun
- McKnight Brain Institute, UF Health College of Medicine, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | | | - Marten Munneke
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Neurology (935), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Department of Neurology (935), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
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Grinshpun-Cohen J, Miron-Shatz T, Berkenstet M, Pras E. The limited effect of information on Israeli pregnant women at advanced maternal age who decide to undergo amniocentesis. Isr J Health Policy Res 2015; 4:23. [PMID: 26284151 PMCID: PMC4538760 DOI: 10.1186/s13584-015-0019-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 04/13/2015] [Indexed: 11/22/2022] Open
Abstract
Background A primary goal of amniocentesis is the detection of trisomy 21 (Down syndrome- DS) in the fetus. This procedure involves a small risk of miscarriage. As the risk of DS increases with maternal age, screening tests (maternal serum triple test and others) and age are used to generate a risk assessment, and amniocentesis is offered to women with high risk. In Israel, amniocentesis is government funded for women of advanced maternal age (AMA, i.e., ≥35 years), even if their risk assessment is low. The purpose of this study was to explore the reasons AMA women undergo amniocentesis, their knowledge about risk estimates, and to evaluate whether their decision is informed. Methods Shortly after undergoing amniocentesis, 42 consecutive women without a medical indication for amniocentesis other than age, completed a questionnaire that assessed their knowledge and opinions regarding screening tests, pregnancy termination, amniocentesis risks and the factors that affected their decision. Results Women rarely deliberated before undergoing amniocentesis. One third of those who had the screening test did not wait for the results before undergoing amniocentesis. Only one third of those who received the screening results remembered their risk estimation before going ahead with amniocentesis. Almost half (41 %) cited “age” as their main reason for undergoing amniocentesis, though only 44 % of these women could recall their age related DS risk. Sixty percent estimated their DS risk as low or very low but still had amniocentesis. Most participants (74 %) stated that they would consider termination of the pregnancy if the fetus was diagnosed with an intellectual deficit. Conclusions These results cast doubt on whether AMA women’s decision to undergo amniocentesis is based on risk estimates, as women seem to disregard risk estimates, and sometimes not even wait for them when making the decision. The policy of funding amniocentesis solely on the basis of age may have led to the conception that being over 35 alone is sufficient reason to undergo amniocentesis. This finding should inform policy makers, as it raises questions about the link between public funding and the choices of individual women, and has implications for healthcare expenditures.
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Affiliation(s)
- Julia Grinshpun-Cohen
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Talya Miron-Shatz
- Center for Medical Decision Making, Ono Academic College, Kiryat Ono, Israel ; Center for Medicine in the Public Interest, New York, NY USA
| | - Michal Berkenstet
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Elon Pras
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cantor SB, Rajan T, Linder SK, Volk RJ. A framework for evaluating the cost-effectiveness of patient decision aids: A case study using colorectal cancer screening. Prev Med 2015; 77:168-73. [PMID: 25979678 PMCID: PMC5629970 DOI: 10.1016/j.ypmed.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/24/2015] [Accepted: 05/05/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Patient decision aids are important tools for facilitating balanced, evidence-based decision making. However, the potential of decision aids to lower health care utilization and costs is uncertain; few studies have investigated the cost-effectiveness of decision aids that change patient behavior. Using an example of a decision aid for colorectal cancer screening, we provide a framework for analyzing the cost-effectiveness of decision aids. METHODS A decision-analytic model with two strategies (decision aid or no decision aid) was used to calculate expected costs in U.S. dollars and benefits measured in life-years saved (LYS). Data from a systematic review of ten studies about decision aid effectiveness was used to calculate the percentage increase in the number of people choosing screening instead of no screening. We then calculated the incremental cost per LYS with the use of the decision aid. RESULTS The no decision aid strategy had an expected cost of $3023 and yielded 18.19 LYS. The decision aid strategy cost $3249 and yielded 18.20 LYS. The incremental cost-effectiveness ratio for the decision aid strategy was $36,126 per LYS. Results were sensitive to the cost of the decision aid and the percentage change in behavior caused by the decision aid. CONCLUSIONS This study provides proof-of-concept evidence for future studies examining the cost-effectiveness of decision aids. The results suggest that decision aids can be beneficial and cost-effective.
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Affiliation(s)
- Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Tanya Rajan
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Suzanne K Linder
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Melnick ER, Keegan J, Taylor RA. Redefining Overuse to Include Costs: A Decision Analysis for Computed Tomography in Minor Head Injury. Jt Comm J Qual Patient Saf 2015; 41:313-22. [DOI: 10.1016/s1553-7250(15)41041-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M, Stephenson T, Bailey S. Choosing Wisely in the UK: the Academy of Medical Royal Colleges' initiative to reduce the harms of too much medicine. BMJ 2015; 350:h2308. [PMID: 25985331 PMCID: PMC4428277 DOI: 10.1136/bmj.h2308] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 12/02/2022]
Abstract
A Malhotra and colleagues explain how and why a US initiative to get doctors to stop using interventions with no benefit is being brought to the UK
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Affiliation(s)
- A Malhotra
- Academy of Medical Royal Colleges, London, UK
| | - D Maughan
- Centre For Sustainable Healthcare, Oxford, UK
| | - J Ansell
- Welsh Institute for Minimal Access Therapy, Cardiff Medicentre, Cardiff, UK
| | - R Lehman
- Department of Primary Health Care, University Of Oxford, Oxford, UK
| | - A Henderson
- Academy of Medical Royal Colleges, London, UK
| | - M Gray
- Better Value Healthcare, Oxford, UK
| | - T Stephenson
- Academy of Medical Royal Colleges, London, UK Institute of Child Health, London, UK
| | - S Bailey
- Academy of Medical Royal Colleges, London, UK
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Panagopoulou E, Montgomery AJ, Tsiga E. Bringing the well being and patient safety research agenda together: why healthy HPs equal safe patients. Front Psychol 2015; 6:211. [PMID: 25774146 PMCID: PMC4342865 DOI: 10.3389/fpsyg.2015.00211] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/11/2015] [Indexed: 11/27/2022] Open
Affiliation(s)
- Efharis Panagopoulou
- Laboratory of Hygiene, Aristotle Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece
| | - Anthony J Montgomery
- Department of Education and Social Policy, University of Macedonia Thessaloniki, Greece
| | - Evangelia Tsiga
- Laboratory of Hygiene, Aristotle Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece
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Agoritsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl EA, Neumann I, Tikkinen KA, Weijden TVD, Elwyn G, Montori VM, Guyatt GH, Vandvik PO. Decision aids that really promote shared decision making: the pace quickens. BMJ 2015; 350:g7624. [PMID: 25670178 PMCID: PMC4707568 DOI: 10.1136/bmj.g7624] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Decision aids can help shared decision making, but most have been hard to produce, onerous to update, and are not being used widely. Thomas Agoritsas and colleagues explore why and describe a new electronic model that holds promise of being more useful for clinicians and patients to use together at the point of care
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Affiliation(s)
- Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada Division of General Internal Medicine, Division of Clinical Epidemiology, University Hospitals of Geneva, Switzerland
| | - Anja Fog Heen
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway Institute for Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Linn Brandt
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway Institute for Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Pablo Alonso-Coello
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER, Epidemiología y Salud Pública, Barcelona, Spain
| | - Annette Kristiansen
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway Institute for Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Elie A Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada Department of Internal Medicine, American University of Beirut, Lebanon
| | - Ignacio Neumann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Kari Ao Tikkinen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada Departments of Urology and Public Health, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Trudy van der Weijden
- Department Family Medicine, School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Glyn Elwyn
- Dartmouth Center for Health Care Delivery Science, Dartmouth Institute for Health Policy and Clinical Practice, Hanover, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, USA
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway Institute for Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Trenaman L, Sadatsafavi M, Almeida F, Ayas N, Lynd L, Marra C, Stacey D, Bansback N. Exploring the Potential Cost-Effectiveness of Patient Decision Aids for Use in Adults with Obstructive Sleep Apnea. Med Decis Making 2014; 35:671-82. [DOI: 10.1177/0272989x14556676] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 09/26/2014] [Indexed: 11/16/2022]
Abstract
Background. There is increasing evidence highlighting the effectiveness of patient decision aids (PtDAs), but evidence supporting their cost-effectiveness is lacking. We consider patients with obstructive sleep apnea (OSA), in whom a PtDA may decrease nonadherence to treatment by empowering patients to receive the option that is most congruent with their own values. Objective. To determine the potential costs and benefits of delivering a PtDA to patients with moderate OSA. Methods. A Markov cohort decision-analytic model was developed for patients with moderate OSA, comparing a PtDA to usual care over 5 years from a societal perspective. Data for patient preference for treatment options was taken from a recent randomized crossover trial, event data (cardiovascular, motor vehicle accidents) came from national databases and published literature. Potential improvements in adherence are unknown, so we considered a realistic range of values. Outcome measures were 5-year costs (in 2010 Canadian dollars), quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results. When adherence to treatment was unchanged, the PtDA strategy was dominated by incurring lower QALYs and higher costs. When nonadherence was decreased by 20% in the PtDA arm (corresponding to an increase in adherence from 63% to 70% for continuous positive airway pressure and from 77% to 82% for mandibular advancement splints in year 1), the ICER fell to $62,414/QALY. Costs associated with the treatment devices and delivering the PtDA had the greatest effect on cost-effectiveness. Limitations. The model relies on surrogate measures and opinions for key parameters. Conclusions: The cost-effectiveness of PtDAs will depend on contextual factors, but a framework is described for properly considering their long-term cost-effectiveness. A number of important questions around the appropriateness of benefit measurement for PtDA trials are highlighted.
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Affiliation(s)
- Logan Trenaman
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Mohsen Sadatsafavi
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Fernanda Almeida
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Najib Ayas
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Larry Lynd
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Carlo Marra
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Dawn Stacey
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (LT, NA, LL, CM, NB)
- Ottawa Hospital Research Institute, Ottawa, Canada (LT, DS)
- Collaboration for Outcomes Research and Evaluations, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada (MS, LL, CM)
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The cost-effectiveness of patient decision aids: A systematic review. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2014; 2:251-7. [PMID: 26250632 DOI: 10.1016/j.hjdsi.2014.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 09/09/2014] [Indexed: 12/11/2022]
Abstract
The Affordable Care Act includes provisions to encourage patient-centered care through the use of shared decision making (SDM) and patient decision aids (PtDA). PtDAs are tools that can help encourage SDM by providing information about competing treatment options and elucidating patients׳ values and preferences. Implementing PtDAs into routine practice may incur additional costs through training or increases in physician time. Prominent commentaries have proposed that these costs might be offset if patients choose less expensive options than their providers. However, the cost-effectiveness of PtDAs to date is unclear. The aim of this study was to review the economic evidence from PtDA trials. Our search identified 5347 articles, with 29 included following full-text review. Only one economic evaluation of a PtDA has been completed, which found a PtDA to be cost-saving in women with menorrhagia. Other studies included in the review indicated that PtDAs will likely increase up-front costs, but in some contexts may reduce short-term costs by reducing the uptake of invasive treatments, such as elective surgery. Few studies comprehensively captured long-term costs or measured benefits in a manner conducive to economic evaluation (QALYs or general health utilities). Our review suggests that policy makers currently have insufficient economic evidence to appropriately consider their investments in PtDAs.
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Dicks LV, Walsh JC, Sutherland WJ. Organising evidence for environmental management decisions: a '4S' hierarchy. Trends Ecol Evol 2014; 29:607-13. [PMID: 25280588 DOI: 10.1016/j.tree.2014.09.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/01/2014] [Accepted: 09/10/2014] [Indexed: 10/24/2022]
Abstract
Making decisions informed by the best-available science is an objective for many organisations managing the environment or natural resources. Yet, available science is still not widely used in environmental policy and practice. We describe a '4S' hierarchy for organising relevant science to inform decisions. This hierarchy has already revolutionised clinical practice. It is beginning to emerge for environmental management, although all four levels need substantial development before environmental decision-makers can reliably and efficiently find the evidence they need. We expose common bypass routes that currently lead to poor or biased representation of scientific knowledge. We argue that the least developed level of the hierarchy is that closest to decision-makers, placing synthesised scientific knowledge into environmental decision support systems.
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Affiliation(s)
- Lynn V Dicks
- Conservation Science Group, Department of Zoology, University of Cambridge, Downing Street, Cambridge CB2 3EJ, UK.
| | - Jessica C Walsh
- Conservation Science Group, Department of Zoology, University of Cambridge, Downing Street, Cambridge CB2 3EJ, UK
| | - William J Sutherland
- Conservation Science Group, Department of Zoology, University of Cambridge, Downing Street, Cambridge CB2 3EJ, UK
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Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. PATIENT EDUCATION AND COUNSELING 2014; 96:281-6. [PMID: 25034637 DOI: 10.1016/j.pec.2014.06.014] [Citation(s) in RCA: 236] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 06/17/2014] [Accepted: 06/25/2014] [Indexed: 05/12/2023]
Abstract
OBJECTIVE As shared decision makes increasing headway in healthcare policy, it is under more scrutiny. We sought to identify and dispel the most prevalent myths about shared decision making. METHODS In 20 years in the shared decision making field one of the author has repeatedly heard mention of the same barriers to scaling up shared decision making across the healthcare spectrum. We conducted a selective literature review relating to shared decision making to further investigate these commonly perceived barriers and to seek evidence supporting their existence or not. RESULTS Beliefs about barriers to scaling up shared decision making represent a wide range of historical, cultural, financial and scientific concerns. We found little evidence to support twelve of the most common beliefs about barriers to scaling up shared decision making, and indeed found evidence to the contrary. CONCLUSION Our selective review of the literature suggests that twelve of the most commonly perceived barriers to scaling up shared decision making across the healthcare spectrum should be termed myths as they can be dispelled by evidence. PRACTICE IMPLICATIONS Our review confirms that the current debate about shared decision making must not deter policy makers and clinicians from pursuing its scaling up across the healthcare continuum.
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Affiliation(s)
- France Légaré
- Research Centre of the CHU of Québec, St-François d'Assise Hospital, Québec, Canada; Department of Family Medicine and Emergency Medicine, Laval University, Québec, Canada.
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Patel S, Ngunjiri A, Hee SW, Yang Y, Brown S, Friede T, Griffiths F, Lord J, Sandhu H, Thistlethwaite J, Tysall C, Underwood M. Primum non nocere: shared informed decision making in low back pain--a pilot cluster randomised trial. BMC Musculoskelet Disord 2014; 15:282. [PMID: 25146587 PMCID: PMC4247192 DOI: 10.1186/1471-2474-15-282] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/29/2014] [Indexed: 11/29/2022] Open
Abstract
Background Low back pain is a common and disabling condition leading to large health service and societal costs. Although there are several treatment options for back pain little is known about how to improve patient choice in treatment selection. The purpose of this study was to pilot a decision support package to help people choose between low back pain treatments. Methods This was a single-centred pilot cluster randomised controlled trial conducted in a community physiotherapy service. We included adults with non-specific low back pain referred for physiotherapy. Intervention participants were sent an information booklet prior to their first consultation. Intervention physiotherapists were trained to enhance their skills in shared informed decision making. Those in the control arm received care as usual. The primary outcome was satisfaction with the treatment received at four months using a five-point Likert Scale dichotomised into “satisfaction” (very satisfied or somewhat satisfied) and “non-satisfaction” (neither satisfied nor dissatisfied, somewhat dissatisfied or very dissatisfied). Results We recruited 148 participants. In the control arm 67% of participants were satisfied with their treatment and in the intervention arm 53%. The adjusted relative risk of being satisfied was 1.28 (95% confidence interval 0.79 to 2.09). For most secondary outcomes the trend was towards worse outcomes in the intervention group. For one measure; the Roland Morris Disability Questionnaire, this difference was clinically important (2.27, 95% confidence interval 0.08 to 4.47). Mean healthcare costs were slightly lower (£38 saving per patient) within the intervention arm but health outcomes were also less favourable (0.02 fewer QALYs); the estimated probability that the intervention would be cost-effective at an incremental threshold of £20,000 per QALY was 16%. Conclusion We did not find that this decision support package improved satisfaction with treatment; it may have had a substantial negative effect on clinical outcome, and is very unlikely to prove cost-effective. That a decision support package might have a clinically important detrimental effect is of concern. To our knowledge this has not been observed previously. Decision support packages should be formally tested for clinical and cost-effectiveness, and safety before implementation. Trial registration Current Controlled Trials ISRCTN46035546 registered on 11/02/10. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-282) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shilpa Patel
- Division of Health Sciences, Warwick Medical School, University of Warwick, CV4 7AL Coventry, UK.
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Abstract
Shared decision-making (SDM), a component of patient-centered care, is the process in which the clinician and patient both participate in decision-making about treatment; information is shared between the parties and both agree with the decision. Shared decision-making is appropriate for health care conditions in which there is more than one evidence-based treatment or management option that have different benefits and risks. The patient's involvement ensures that the decisions regarding treatment are sensitive to the patient's values and preferences. Audiologic rehabilitation requires substantial behavior changes on the part of patients and includes benefits to their communication as well as compromises and potential risks. This article identifies the importance of shared decision-making in audiologic rehabilitation and the changes required to implement it effectively.
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Affiliation(s)
- Helen Pryce
- Centre for Hearing and Balance Studies, University of BristolBristol, England
| | - Amanda Hall
- Centre for Hearing and Balance Studies, University of BristolBristol, England
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