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Zeng A, Tang Q, O'Hagan E, McCaffery K, Ijaz K, Quiroz JC, Kocaballi AB, Rezazadegan D, Trivedi R, Siette J, Shaw T, Makeham M, Thiagalingam A, Chow CK, Laranjo L. Use of digital patient decision-support tools for atrial fibrillation treatments: a systematic review and meta-analysis. BMJ Evid Based Med 2024:bmjebm-2023-112820. [PMID: 38950915 DOI: 10.1136/bmjebm-2023-112820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES To assess the effects of digital patient decision-support tools for atrial fibrillation (AF) treatment decisions in adults with AF. STUDY DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Eligible randomised controlled trials (RCTs) evaluated digital patient decision-support tools for AF treatment decisions in adults with AF. INFORMATION SOURCES We searched MEDLINE, EMBASE and Scopus from 2005 to 2023.Risk-of-bias (RoB) assessment: We assessed RoB using the Cochrane Risk of Bias Tool 2 for RCTs and cluster RCT and the ROBINS-I tool for quasi-experimental studies. SYNTHESIS OF RESULTS We used random effects meta-analysis to synthesise decisional conflict and patient knowledge outcomes reported in RCTs. We performed narrative synthesis for all outcomes. The main outcomes of interest were decisional conflict and patient knowledge. RESULTS 13 articles, reporting on 11 studies (4 RCTs, 1 cluster RCT and 6 quasi-experimental) met the inclusion criteria. There were 2714 participants across all studies (2372 in RCTs), of which 26% were women and the mean age was 71 years. Socioeconomically disadvantaged groups were poorly represented in the included studies. Seven studies (n=2508) focused on non-valvular AF and the mean CHAD2DS2-VASc across studies was 3.2 and for HAS-BLED 1.9. All tools focused on decisions regarding thromboembolic stroke prevention and most enabled calculation of individualised stroke risk. Tools were heterogeneous in features and functions; four tools were patient decision aids. The readability of content was reported in one study. Meta-analyses showed a reduction in decisional conflict (4 RCTs (n=2167); standardised mean difference -0.19; 95% CI -0.30 to -0.08; p=0.001; I2=26.5%; moderate certainty evidence) corresponding to a decrease in 12.4 units on a scale of 0 to 100 (95% CI -19.5 to -5.2) and improvement in patient knowledge (2 RCTs (n=1057); risk difference 0.72, 95% CI 0.68, 0.76, p<0.001; I2=0%; low certainty evidence) favouring digital patient decision-support tools compared with usual care. Four of the 11 tools were publicly available and 3 had been implemented in healthcare delivery. CONCLUSIONS In the context of stroke prevention in AF, digital patient decision-support tools likely reduce decisional conflict and may result in little to no change in patient knowledge, compared with usual care. Future studies should leverage digital capabilities for increased personalisation and interactivity of the tools, with better consideration of health literacy and equity aspects. Additional robust trials and implementation studies are warranted. PROSPERO REGISTRATION NUMBER CRD42020218025.
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Affiliation(s)
- Aileen Zeng
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Queenie Tang
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Edel O'Hagan
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Kiran Ijaz
- Affective Interactions lab, School of Architecture, Design and Planning, The University of Sydney, Sydney, New South Wales, Australia
| | - Juan C Quiroz
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ahmet Baki Kocaballi
- School of Computer Science, Faculty of Engineering & Information Technology, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Dana Rezazadegan
- Department of Computing Technologies, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Ritu Trivedi
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joyce Siette
- The MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Penrith, New South Wales, Australia
| | - Timothy Shaw
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Meredith Makeham
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Aravinda Thiagalingam
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Liliana Laranjo
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Nelson AJ, Pagidipati NJ, Bosworth HB. Improving medication adherence in cardiovascular disease. Nat Rev Cardiol 2024; 21:417-429. [PMID: 38172243 DOI: 10.1038/s41569-023-00972-1] [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] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.
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Affiliation(s)
- Adam J Nelson
- Victorian Heart Institute, Melbourne, Victoria, Australia
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
- Population Health Sciences, Duke University, Durham, NC, USA.
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3
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Wu S, Yang C, He L, Hu Z, Yao J. Meta-synthesis of qualitative studies on patient perceptions and requirements during the perioperative period of robotic surgery. J Robot Surg 2024; 18:44. [PMID: 38240864 DOI: 10.1007/s11701-023-01791-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/02/2023] [Indexed: 01/23/2024]
Abstract
This research undertakes a comprehensive evaluation and amalgamation of patient experiences and requirements during the perioperative period of robot-assisted surgery (RS), with the goal of enriching clinical practice with patient-centered insights. A meta-synthesis was performed and reported according to the preferred reporting Items for systematic reviews and meta-analyses and the enhancing transparency in reporting the synthesis of qualitative research statement. A rigorous literature search was conducted across multiple Chinese and English databases, namely PubMed, CINAHL (EBSCO), Embase, Web of Science, Scopus, China Biomedical Literature Database (CBLD), China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Information. This study incorporated ten qualitative studies, the outcomes were classified into three overarching themes: personalized patient requirements related to RS; the psychological and physiological experiences of patients; and the divergent perceptions of male and female patients regarding RS. Greater emphasis needs to be placed on patient comprehension of RS, augmenting focus on patient psychological experiences, recognizing unique patient needs at various stages of RS, and providing patients with specialized knowledge and technical support.
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Affiliation(s)
- Shuang Wu
- School of Nursing, Shaanxi University of Chinese Medicine, Century Avenue, Chenyangzhai, Qindu District, Xianyang, 712046, Shaanxi, China
| | - Chunzhi Yang
- School of Nursing, Shaanxi University of Chinese Medicine, Century Avenue, Chenyangzhai, Qindu District, Xianyang, 712046, Shaanxi, China
| | - Liu He
- School of Nursing, Shaanxi University of Chinese Medicine, Century Avenue, Chenyangzhai, Qindu District, Xianyang, 712046, Shaanxi, China
| | - Zhixuan Hu
- School of Nursing, Shaanxi University of Chinese Medicine, Century Avenue, Chenyangzhai, Qindu District, Xianyang, 712046, Shaanxi, China
| | - Jie Yao
- School of Nursing, Shaanxi University of Chinese Medicine, Century Avenue, Chenyangzhai, Qindu District, Xianyang, 712046, Shaanxi, China.
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Sweeney J, Tichnell C, Christian S, Pendelton C, Murray B, Roter DL, Jamal L, Calkins H, James CA. Characterizing Decision-Making Surrounding Exercise in ARVC: Analysis of Decisional Conflict, Decisional Regret, and Shared Decision-Making. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2023; 16:e004133. [PMID: 38014565 PMCID: PMC10729899 DOI: 10.1161/circgen.123.004133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Limiting high-intensity exercise is recommended for patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) due to its association with penetrance, arrhythmias, and structural progression. Guidelines recommend shared decision-making (SDM) for exercise level, but there is little evidence regarding its impact. Therefore, we sought to evaluate the extent and implications of SDM for exercise, decisional conflict, and decisional regret in patients with ARVC and at-risk relatives. METHODS Adults diagnosed with ARVC or with positive genetic testing enrolled in the Johns Hopkins ARVC Registry were invited to complete a questionnaire that included exercise history and current exercise, SDM (SDM-Q-9), decisional conflict, and decisional regret. RESULTS The response rate was 64.8%. Two-thirds of participants (68.0%, n=121) reported clinically significant decisional conflict regarding exercise at diagnosis/genetic testing (DCS [decisional conflict scale]≥25), and half (55.1%, n=98) in the past year. Prevalence of decisional regret was also high with 55.3% (n=99) reporting moderate to severe decisional regret (DRS [decisional regret scale]≥25). The extent of SDM was highly variable ranging from no (0) to perfect (100) SDM (mean, 59.6±25.0). Those diagnosed in adolescence (≤age 21) reported significantly more SDM (P=0.013). Importantly, SDM was associated with less decisional conflict (ß=-0.66, R2=0.567, P<0.01) and decisional regret (ß=-0.37, R2=0.180, P<0.001) and no difference in vigorous intensity aerobic exercise in the 6 months after diagnosis/genetic testing or the past year (P=0.56; P=0.34, respectively). CONCLUSIONS SDM is associated with lower decisional conflict and decisional regret; and no difference in postdiagnosis exercise. Our data thus support SDM as the preferred model for exercise discussions for ARVC.
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Affiliation(s)
- Jessica Sweeney
- Johns Hopkins Bloomberg School of Public Health (J.S., D.L.R.), Johns Hopkins University, Baltimore
- National Human Genome Research Institute (J.S.), National Institutes of Health, Bethesda, MD
| | - Crystal Tichnell
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Susan Christian
- Department of Medical Genetics, University of Alberta, Edmonton, Canada (S.C.)
| | - Catherine Pendelton
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Brittney Murray
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Debra L. Roter
- Johns Hopkins Bloomberg School of Public Health (J.S., D.L.R.), Johns Hopkins University, Baltimore
| | - Leila Jamal
- Center for Cancer Research, National Cancer Institute (L.J.), National Institutes of Health, Bethesda, MD
- Department of Bioethics, Clinical Center (L.J.), National Institutes of Health, Bethesda, MD
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Cynthia A. James
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
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Brown SA, Hamid A, Pederson E, Bs AH, Maddula R, Goodman R, Lamberg M, Caraballo P, Noseworthy P, Lukan O, Echefu G, Berman G, Choudhuri I. Simplified rules-based tool to facilitate the application of up-to-date management recommendations in cardio-oncology. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:37. [PMID: 37891699 PMCID: PMC10605976 DOI: 10.1186/s40959-023-00179-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 05/24/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Millions of cancer survivors are at risk of cardiovascular diseases, a leading cause of morbidity and mortality. Tools to potentially facilitate implementation of cardiology guidelines, consensus recommendations, and scientific statements to prevent atherosclerotic cardiovascular disease (ASCVD) and other cardiovascular diseases are limited. Thus, inadequate utilization of cardiovascular medications and imaging is widespread, including significantly lower rates of statin use among cancer survivors for whom statin therapy is indicated. METHODS In this methodological study, we leveraged published guidelines documents to create a rules-based tool to include guidelines, expert consensus, and medical society scientific statements relevant to point of care cardiovascular disease prevention in the cardiovascular care of cancer survivors. Any overlap, redundancy, or ambiguous recommendations were identified and eliminated across all converted sources of knowledge. The integrity of the tool was assessed with use case examples and review of subsequent care suggestions. RESULTS An initial selection of 10 guidelines, expert consensus, and medical society scientific statements was made for this study. Then 7 were kept owing to overlap and revisions in society recommendations over recent years. Extensive formulae were employed to translate the recommendations of 7 selected guidelines into rules and proposed action measures. Patient suitability and care suggestions were assessed for several use case examples. CONCLUSION A simple rules-based application was designed to provide a potential format to deliver critical cardiovascular disease best-practice prevention recommendations at the point of care for cancer survivors. A version of this tool may potentially facilitate implementing these guidelines across clinics, payers, and health systems for preventing cardiovascular diseases in cancer survivors. TRIAL REGISTRATION ClinicalTrials.Gov Identifier: NCT05377320.
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Affiliation(s)
- Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | | | | | | | | | | | | | | | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Opeoluwa Lukan
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, USA
| | - Gift Echefu
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, USA
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
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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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Wang PJ, Lu Y, Mahaffey KW, Lin A, Morin DP, Sears SF, Chung MK, Russo AM, Lin B, Piccini J, Hills MT, Berube C, Pundi K, Baykaner T, Garay G, Lhamo K, Rice E, Pourshams IA, Shah R, Newswanger P, DeSutter K, Nunes JC, Albert MA, Schulman KA, Heidenreich PA, Bunch TJ, Sanders LM, Turakhia M, Verghese A, Stafford RS. Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. J Am Heart Assoc 2023; 12:e028562. [PMID: 36342828 PMCID: PMC9973612 DOI: 10.1161/jaha.122.028562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision-making toolkit was developed using patient-centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision-making toolkit. The primary end point was the validated 16-item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10-item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the 2 arms (16.4 versus 9.4; Mann-Whitney U-statistics=0.550; P=0.007). For the secondary end point of 1-month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision-making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.
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Affiliation(s)
- Paul J. Wang
- Stanford University Department of MedicinePalo AltoCA
| | - Ying Lu
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Amy Lin
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | | | - Samuel F. Sears
- East Carolina University Department of PsychologyGreenvilleNC
| | - Mina K. Chung
- Cleveland Clinic Foundation Department of MedicineClevelandOH
| | | | - Bryant Lin
- Stanford University Department of MedicinePalo AltoCA
| | | | | | | | - Krishna Pundi
- Stanford University Department of MedicinePalo AltoCA
| | - Tina Baykaner
- Stanford University Department of MedicinePalo AltoCA
| | - Gotzone Garay
- Stanford University Department of MedicinePalo AltoCA
| | - Karma Lhamo
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Eli Rice
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | - Rushil Shah
- Stanford University Department of MedicinePalo AltoCA
| | - Paul Newswanger
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | | | - Michelle A. Albert
- University of California San Francisco Department of MedicineSan FranciscoCA
| | | | - Paul A. Heidenreich
- Stanford University Department of MedicinePalo AltoCA
- Palo Alto Veterans Administration Health Care Department of MedicinePalo AltoCA
| | - T. Jared Bunch
- University of Utah Department of MedicineSalt Lake CityUT
| | | | - Mintu Turakhia
- Stanford University Department of MedicinePalo AltoCA
- iRhythm TechnologiesSan FranciscoCA
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10
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Spencer-Bonilla G, Branda ME, Kunneman M, Bellolio F, Burnett B, Guyatt G, Montori VM. Encounter-based randomization did not result in contamination in a shared decision-making trial: a secondary analysis. J Clin Epidemiol 2022; 152:185-192. [PMID: 36220625 DOI: 10.1016/j.jclinepi.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To estimate the level of contamination in an encounter-randomized trial evaluating a shared decision-making (SDM) tool. STUDY DESIGN AND SETTING We assessed contamination at three levels: (1) tool contamination (whether the tool was physically present in the usual care encounter), (2) functional contamination (whether components of the SDM tool were recreated in the usual care encounters without directly accessing the tool), and (3) learned contamination (whether clinicians "got better at SDM" in the usual care encounters as assessed by the OPTION-12 score). For functional and learned contamination, the interaction with the number of exposures to the tool was assessed. RESULTS We recorded and analyzed 830 of 922 randomized encounters. Of the 411 recorded encounters randomized to usual care, the SDM tool was used in nine (2.2%) encounters. Clinicians discussed at least one patient-important issue in 377 usual care encounters (92%) and the risk of stroke in 214 encounters (52%). We found no significant interaction between number of times the SDM tool was used and subsequent functional or learned contamination. CONCLUSION Despite randomly assigning clinicians to use an SDM tool in some and not other encounters, we found no evidence of contamination in usual care encounters.
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Affiliation(s)
- Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Fernanda Bellolio
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | - Gordon Guyatt
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
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11
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Branda ME, Kunneman M, Meza-Contreras AI, Shah ND, Hess EP, LeBlanc A, Linderbaum JA, Nelson DM, Mc Donah MR, Sanvick C, Van Houten HK, Coylewright M, Dick SR, Ting HH, Montori VM. Shared Decision-Making for Patients Hospitalized with Acute Myocardial Infarction: A Randomized Trial. Patient Prefer Adherence 2022; 16:1395-1404. [PMID: 35673524 PMCID: PMC9167591 DOI: 10.2147/ppa.s363528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Adherence to guideline-recommended medications after acute myocardial infarction (AMI) is suboptimal. Patient fidelity to treatment regimens may be related to their knowledge of the risk of death following AMI, the pros and cons of medications, and to their involvement in treatment decisions. Shared decision-making may improve both patients' knowledge and involvement in treatment decisions. METHODS In a pilot trial, patients hospitalized with AMI were randomized to the use of the AMI Choice conversation tool or to usual care. AMI Choice includes a pictogram of the patient's estimated risk of mortality at 6 months with and without guideline-recommended medications, ie, aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors. Primary outcomes were patient knowledge and conflict with the decision made assessed via post-encounter surveys. Secondary outcomes were patient involvement in the decision-making process (observer-based OPTION12 scale) and 6-month medication adherence. RESULTS Patient knowledge of the expected survival benefit from taking medications was significantly higher (62% vs 16%, p<0.0001) in the AMI Choice group (n = 53) compared to the usual care group (n = 53). Both groups reported similarly low levels of conflict with the decision to start the medications (13 (SD 24.2) vs 16 (SD 22) out of 100; p=0.16). The extent to which clinicians in the AMI Choice group involved their patients in the decision-making process was high (OPTION12 score 53 out of 100, SD 12). Medication adherence at 6-months was relatively high in both groups and not different between groups. CONCLUSION The AMI Choice conversation tool improved patients' knowledge of their estimated risk of short-term mortality after an AMI and the pros and cons of treatments to reduce this risk. The effect on patient fidelity to recommended medications of using this SDM tool and of SDM in general should be tested in larger trials enrolling patients at high risk for nonadherence. TRIAL REGISTRATION NUMBER NCT00888537.
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Affiliation(s)
- Megan E Branda
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Alejandra I Meza-Contreras
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Annie LeBlanc
- Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Jane A Linderbaum
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Danika M Nelson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | - Holly K Van Houten
- Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA
| | - Megan Coylewright
- Section of Cardiovascular Medicine, Erlanger Heart and Lung Institute, Chattanooga, TN, USA
| | - Sara R Dick
- Education Project Management Office, Mayo Clinic, Rochester, MN, USA
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Correspondence: Victor M Montori, 200 First Street SW, Rochester, MN, 55905, USA, Tel +1 507-284-2511, Email
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