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Kaplan H, Kostick-Quenet K, Lang B, Volk RJ, Blumenthal-Barby J. Impact of personalized risk scores on shared decision making in left ventricular assist device implantation: Findings from a qualitative study. PATIENT EDUCATION AND COUNSELING 2024; 130:108418. [PMID: 39288559 DOI: 10.1016/j.pec.2024.108418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 08/26/2024] [Accepted: 08/31/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE To assess stakeholders' perspectives on integrating personalized risk scores (PRS) into left ventricular assist device (LVAD) implantation decisions and how these perspectives might impact shared decision making (SDM). METHODS We conducted 40 in-depth interviews with physicians, nurse coordinators, patients, and caregivers about integrating PRS into LVAD implantation decisions. A codebook was developed to identify thematic patterns, and quotations were consolidated for analysis. We used Thematic Content Analysis in MAXQDA software to identify themes by abstracting relevant quotes. RESULTS Clinicians had varying preferences regarding PRS integration into LVAD decision making, while patients and caregivers preferred real-time discussions about PRS with their physicians. Physicians voiced concerns about time constraints and suggested delegating PRS discussions to advanced practice providers or nurse coordinators. CONCLUSIONS Integrating PRS information into LVAD decision aids presents both opportunities and challenges for SDM. Given variable preferences among clinicians and patients, clinicians should elicit patients' desired role in the decision-making process. Addressing time constraints and ensuring patient-centered care will be crucial for optimizing SDM. Practice implications Clinicians should elicit patient preferences for PRS information disclosure and address challenges, such as time constraints and delegation of PRS discussions to other team members.
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Affiliation(s)
- Holland Kaplan
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA; Section of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Benjamin Lang
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Junger N, Hirsch O. Ethics of Nudging in the COVID-19 Crisis and the Necessary Return to the Principles of Shared Decision Making: A Critical Review. Cureus 2024; 16:e57960. [PMID: 38601812 PMCID: PMC11005480 DOI: 10.7759/cureus.57960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 04/12/2024] Open
Abstract
Nudging, a controversial technique for modifying people's behavior in a predictable way, is claimed to preserve freedom of choice while simultaneously influencing it. Nudging had been largely confined to situations such as promoting healthy eating choices but has been employed in the coronavirus disease 2019 (COVID-19) crisis in a shift towards measures that involve significantly less choice, such as shoves and behavioral prods. Shared decision making (SDM), a method for direct involvement and autonomy, is an alternative approach to communicate risk. Predominantly peer-reviewed scientific publications from standard literature databases like PubMed, PsycInfo, and Psyndex were evaluated in a narrative review. The so-called fear nudges, as well as the dissemination of strongly emotionalizing or moralizing messages can lead to intense psycho-physical stress. The use of these nudges by specialized units during the COVID-19 pandemic generated a societal atmosphere of fear that precipitated a deterioration of the mental and physical health of the population. Major recommendations of the German COVID-19 Snapshot Monitoring (COSMO) study, which are based on elements of nudging and coercive measures, do not comply with ethical principles, basic psychological principles, or evidence-based data. SDM was misused in the COVID-19 crisis, which helped to achieve one-sided goals of governments. The emphasis on utilitarian thinking is criticized and the unethical behavior of decision makers is explained by both using the concept of moral disengagement and the maturity level of coping strategies. There should be a return to an open-ended, democratic, and pluralistic scientific debate without using nudges. It is therefore necessary to return to the origins of SDM.
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Affiliation(s)
- Nancy Junger
- Psychology, Independent Researcher, Tübingen, DEU
| | - Oliver Hirsch
- Psychology, FOM University of Applied Sciences, Siegen, DEU
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Palmer Kelly E, Rush LJ, Eramo JL, Melnyk HL, Tarver WL, Waterman BL, Gustin J, Pawlik TM. Gaps in Patient-Centered Decision-Making Related to Complex Surgery: A Mixed-Methods Study. J Surg Res 2024; 295:740-745. [PMID: 38142577 DOI: 10.1016/j.jss.2023.11.070] [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: 07/10/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION We sought to understand the perceptions of surgeons around patient preferred roles in decision-making and their approaches to patient-centered decision-making (PCDM). METHODS A concurrent embedded mixed-methods design was utilized among a cohort of surgeons performing complex surgical procedures. Data were collected through online surveys. Associations between perceptions and PCDM approaches were examined. RESULTS Among 241 participants, most respondents were male (67.2%) with an average age of 47.6 y (standard deviation = 10.3); roughly half (52.4%) had practiced medicine for 10 or more years. Surgeons most frequently agreed (94.2%) with the statement, "Patients prefer to make health decisions on their own after seriously considering their physician's opinion." Conversely, surgeons most frequently disagreed (73.0%) with the statement, "Patients prefer that their physician make health decisions for them." Nearly one-third (30.4%) of surgeon qualitative responses (n = 115) indicated that clinical/biological information would help them tailor their approach to PCDM. Only 12.2% of respondents indicated that they assess patient preferences regarding both decision-making and information needs. CONCLUSIONS Surgeons most frequently agree that patients want to make their own health decisions after seriously considering their physicians opinion. A greater focus on what information surgeons should know before treatment decision-making may help optimize patient experience and outcomes related to complex surgical procedures.
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Affiliation(s)
| | - Laura J Rush
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Jennifer L Eramo
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Halia L Melnyk
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Willi L Tarver
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, Columbus, Ohio; Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Brittany L Waterman
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jillian Gustin
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Cowan BA, Olivier K, Tombal B, Wefel JS. Treatment-Related Cognitive Impairment in Patients with Prostate Cancer: Patients' Real-World Insights for Optimizing Outcomes. Adv Ther 2024; 41:476-491. [PMID: 37979089 PMCID: PMC10838823 DOI: 10.1007/s12325-023-02721-9] [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: 09/11/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
Cognitive impairment (CI) is an issue that needs to be at the forefront of unmet healthcare needs in patients with prostate cancer (PCa) as it can negatively impact quality of life during long-term care. CI in patients with prostate cancer is thought to be influenced by treatment, androgen deprivation therapy (ADT), and novel androgen receptor (AR) pathway inhibitors in particular; however, current understanding is limited on how treatment affects cognition. Additionally, the experience of patients with CI who are receiving PCa treatment is not well understood or represented in clinical literature, which is a barrier to optimal patient outcomes in managing prostate cancer treatment-related cognitive impairment (PCa-TRCI). To help understand the patient journey and elucidate management gaps in PCa-TRCI, an international roundtable of healthcare provider and patient panelists was convened. The panelists focused on four key topic areas: (1) the patient experience when afflicted with, or at risk of, PCa-TRCI, (2) the physical, emotional, and social impact of CI on patients' quality of life (QoL), (3) the challenges that patients with PCa-TRCI face, and their impact on clinical decision-making, and (4) ways in which managing PCa-TRCI should evolve to improve patient outcomes. The purpose of the roundtable was to include patients in a direct discussion with healthcare providers (HCPs) regarding the patient journey and highlight real-world evidence of areas where patient outcomes could be improved in the absence of clinical evidence. The resulting discussion highlighted important healthcare gaps for patients with, and at risk of, PCa-TRCI and offered potential solutions as a roadmap to effective medicine.
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Affiliation(s)
| | - Kara Olivier
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Bertrand Tombal
- Division of Urology at the Université catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
| | - Jeffrey S Wefel
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Sacks GD, Shin P, Braithwaite RS, Soares KC, Kingham TP, D'Angelica MI, Drebin JA, Jarnagin WR, Wei AC. The Influence of Patient Preference on Surgeons' Treatment Recommendations in the Management of Intraductal Papillary Mucinous Neoplasms. Ann Surg 2023; 278:e1068-e1072. [PMID: 36804447 DOI: 10.1097/sla.0000000000005829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasms (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. BACKGROUND Surgeons vary widely in management of IPMN. METHODS We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. RESULTS One hundred and fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20%-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs. 5%) more likely to recommend resection than those who were below the median (95% CI: 11.34%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs. 15.0, P =0.06; V2: 7.0 vs. 15.0, P =0.05). CONCLUSIONS The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.
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Affiliation(s)
- Greg D Sacks
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
- VA New York Harbor Healthcare System, New York, NY
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Shin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Alice C Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
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Gore Moses R, Nieters A, Valentine KD, Wooters M, Wynn J, Wardyn A, Amendola L, Sepucha KR, Shannon KM. Performance of the shared decision-making process scale for use in evaluation of hereditary cancer genetic testing decisions. J Genet Couns 2023; 32:957-964. [PMID: 37069832 DOI: 10.1002/jgc4.1704] [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: 11/01/2022] [Revised: 02/18/2023] [Accepted: 03/18/2023] [Indexed: 04/19/2023]
Abstract
This study aimed to evaluate feasibility, acceptability, reliability, and validity of the existing four-item Shared Decision Making (SDM) Process Scale for use in evaluating genetic testing decisions. Patients from a large hereditary cancer genetics practice were invited to participate in a two-part survey after completing pre-test genetic counseling. The online survey included the SDM Process Scale and the SURE scale, a measure of decisional conflict. SDM Process scores were compared to SURE scores to test convergent validity, and respondents were sent a second survey 1 week later to assess retest reliability. The response rate was 65% (n = 259/398) and missing data was low (<1%). SDM scores ranged from zero to four with a mean of 2.3 (SD = 1.1). Retest reliability was good, with intraclass correlation of 0.84, 95% confidence interval (0.79, 0.88). No relationship was found between SDM Process scores and decisional conflict (p = 0.46), likely because 85% of participants reported no decisional conflict. The four-item SDM Process Scale demonstrated feasibility, acceptability, and retest reliability, but not convergent validity with decisional conflict. These findings provide initial evidence for use of this scale to measure patient perceptions of SDM in pre-test counseling for hereditary cancer genetic testing.
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Affiliation(s)
- Rachel Gore Moses
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Amanda Nieters
- Massachusetts General Hospital Center for Cancer Risk Assessment, Boston, Massachusetts, USA
| | - K D Valentine
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mackenzie Wooters
- Massachusetts General Hospital Center for Cancer Risk Assessment, Boston, Massachusetts, USA
| | - Julia Wynn
- Billion to One, Inc., Menlo Park, California, USA
| | - Amy Wardyn
- School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | | | - Karen R Sepucha
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kristen M Shannon
- Massachusetts General Hospital Center for Cancer Risk Assessment, Boston, Massachusetts, USA
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7
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Annadanam S, Garg G, Fagerlin A, Powell C, Chen E, Segal JH, Ojo A, Wright Nunes J. Patient-Centered Outcomes With a Multidisciplinary CKD Care Team Approach: An Observational Study. Kidney Med 2023; 5:100602. [PMID: 36960384 PMCID: PMC10027557 DOI: 10.1016/j.xkme.2023.100602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale & Objective Multidisciplinary chronic kidney disease (CKD) care has been associated with improved clinical outcomes in comparison to general nephrology care. However, there is little research examining the impact of multidisciplinary care on patient-centered outcomes. We examined if a multidisciplinary approach to CKD care was associated with 4 patient-centered outcomes. Study Design Cross-sectional study design using previously established surveys to assess patient-centered outcomes in participants with nondialysis CKD. Setting & Participants Adults with CKD stages 1-5 who had not undergone transplant or were not on dialysis. Exposures General nephrology care or multidisciplinary care. Patients receiving multidisciplinary care were seen by a pharmacist, social worker, dietitian, and nephrologist, whereas patients receiving general nephrology care only saw a nephrologist. Outcomes Four patient-centered outcomes: CKD-specific knowledge, disease-related stress, perception of overall health, and perception of health status compared to 1 year ago. Analytical Approach Differences were examined using a Welch 2-sample t test and linear regression model. Results Mean age of participants was 60 years with standard deviation of 17 years. 182 (77%) patients were White, and 230 (96%) had formal education greater than or equal to high school. 121 (49%) were women, and 215 (88%) had CKD stage 3-5. 77 (31%) received multidisciplinary care. We did not identify any significant differences in patient knowledge, stress, or perception of health between multidisciplinary and general nephrology care. However, notably, patients in multidisciplinary care were older and had more advanced CKD than those in general nephrology care. Limitations Cross-sectional study designs only identify associations. Study was conducted at clinics located within 30 miles of each other, limiting generalizability. Conclusions Our results suggest that a team-based approach to care can better support sicker, more vulnerable patients so that they can achieve similar patient-centered outcomes compared to patients who are younger and with less advanced CKD.
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Affiliation(s)
- Surekha Annadanam
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gunjan Garg
- Kidney Disease Program, Nephrology, University of Louisville, Louisville, Kentucky
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, and Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, Utah
| | - Corey Powell
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
| | - Emily Chen
- Center of Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan H. Segal
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Akinlolu Ojo
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Julie Wright Nunes
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Address for Correspondence: Julie Wright Nunes, MD, MPH, Division of Nephrology, Department of Internal Medicine, University of Michigan, 3rd Floor Taubman Center - Nephrology, 1500 East Medical Center Drive, Ann Arbor, MI 48109.
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Terman SW, Aschmann HE, Hutton DW, Burke JF. Best-worst scaling preferences among patients with well-controlled epilepsy: Pilot results. PLoS One 2023; 18:e0282658. [PMID: 36867630 PMCID: PMC9983827 DOI: 10.1371/journal.pone.0282658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/20/2023] [Indexed: 03/04/2023] Open
Abstract
Epilepsy is a common, serious condition. Fortunately, seizure risk decreases with increasing seizure-free time on antiseizure medications (ASMs). Eventually, patients may consider whether to stop ASMs, which requires weighing treatment benefit versus burden. We developed a questionnaire to quantify patient preferences relevant to ASM decision-making. Respondents rated how concerning they would finding relevant items (e.g., seizure risks, side effects, cost) on a Visual Analogue Scale (VAS, 0-100) and then repeatedly chose the most and least concerning item from subsets (best-worst scaling, BWS). We pretested with neurologists, then recruited adults with epilepsy who were seizure-free at least one year. Primary outcomes were recruitment rate, and qualitative and Likert-based feedback. Secondary outcomes included VAS ratings and best-minus-worst scores. Thirty-one of 60 (52%) contacted patients completed the study. Most patients felt VAS questions were clear (28; 90%), easy to use (27; 87%), and assessed preferences well (25; 83%). Corresponding results for BWS questions were 27 (87%), 29 (97%), and 23 (77%). Physicians suggested adding a 'warmup' question showing a completed example and simplifying terminology. Patients suggested ways to clarify instructions. Cost, inconvenience of taking medication, and laboratory monitoring were the least concerning items. Cognitive side effects and a 50% seizure risk in the next year were the most concerning items. Twelve (39%) of patients made at least one 'inconsistent choice' for example ranking a higher seizure risk as lower concern compared with a lower seizure risk, though 'inconsistent choices' represented only 3% of all question blocks. Our recruitment rate was favorable, most patients agreed the survey was clear, and we describe areas for improvement. 'Inconsistent' responses may lead us to collapse seizure probability items into a single 'seizure' category. Evidence regarding how patients weigh benefits and harms may inform care and guideline development.
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Affiliation(s)
- Samuel W. Terman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Hélène E. Aschmann
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
- Epidemiology Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - David W. Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - James F. Burke
- Department of Neurology, the Ohio State University, Columbus, Ohio, United States of America
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Palmer Kelly E, Myers B, McGee J, Hyer M, Tsilimigras DI, Pawlik TM. Surgeon Strategies to Patient-Centered Decision-making in Cancer Care: Validation and Applications of a Conceptual Model. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1719-1726. [PMID: 33942256 DOI: 10.1007/s13187-021-02017-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
We sought to construct and validate a model of cancer surgeon approaches to patient-centered decision-making (PCDM) and compare applications of that model relative to surgical specialties. Ten PCDM strategies were assessed using a cross-sectional survey administered online to 295 board-certified cancer surgeons. Structural equation modeling was used to empirically validate and compare approaches to PCDM. Within the full sample, 7 strategies comprised a latent construct labeled, "physical & emotional accessibility," associated with surgeon approaches to PCDM (β = 0.37, p < .05). Three individual strategies were included: "expectations (Q4)" (β = 0.52, p < .05), "decision preferences (Q5) (β = 0.47, p < .05), and "access medical information (Q3)" (β = 0.75). Surgical specialties for subgroup analysis were classified as general/other (67.6%) or hepato-pancreato-biliary and upper gastrointestinal (HPB/UGI) (34.2%). For general/other surgeons, 7 individual strategies composed the model of surgeon approaches to PCDM, with "time (Q6) (β = 0.70, p < .001) and "therapeutic relationship building (Q9)" (β = 0.69, p < .001) being the strongest predictors. The HPB/UGI model included 2 latent constructs labeled "physical accessibility" (β = 0.72, p < .05) and "creating a decision-making dialogue" (β = 0.62) as well as the individual strategy, "effective communication (Q8)" (β = 0.51, p < .05). Although models of surgeon PCDM varied, there were 4 overlapping strategies, including effective communication. Tailoring models of PCDM may improve surgeon uptake and thus, overall patient satisfaction with their cancer care.
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Affiliation(s)
| | | | | | - Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Taksler GB, Le P, Hu B, Alberts J, Flynn AJ, Rothberg MB. Personalized Disease Prevention (PDP): study protocol for a cluster-randomized clinical trial. Trials 2022; 23:892. [PMID: 36273151 PMCID: PMC9587586 DOI: 10.1186/s13063-022-06750-7] [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] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The US Preventive Services Task Force recommends 25 primary preventive services for middle-aged adults, but it can be difficult to do them all. METHODS The Personalized Disease Prevention (PDP) cluster-randomized clinical trial will evaluate whether patients and their providers benefit from an evidence-based decision tool to prioritize preventive services based on their potential to improve quality-adjusted life expectancy. The decision tool will be individualized for patient risk factors and available in the electronic health record. This Phase III trial seeks to enroll 60 primary care providers (clusters) and 600 patients aged 40-75 years. Half of providers will be assigned to an intervention to utilize the decision tool with approximately 10 patients each, and half will be assigned to usual care. Mixed-methods follow-up will include collection of preventive care utilization from electronic health records, patient and physician surveys, and qualitative interviews. We hypothesize that quality-adjusted life expectancy will increase by more in patients who receive the intervention, as compared with controls. DISCUSSION PDP will test a novel, holistic approach to help patients and providers prioritize the delivery of preventive services, based on patient risk factors in the electronic health record. TRIAL REGISTRATION ClinicalTrials.gov NCT05463887. Registered on July 19, 2022.
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Affiliation(s)
- Glen B Taksler
- Cleveland Clinic Community Care, Cleveland Clinic, 9500 Euclid Ave., G10, Cleveland, OH, USA.
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
- Population Health Research Institute, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA.
| | - Phuc Le
- Cleveland Clinic Community Care, Cleveland Clinic, 9500 Euclid Ave., G10, Cleveland, OH, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Jay Alberts
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Allen J Flynn
- School of Information and Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Michael B Rothberg
- Cleveland Clinic Community Care, Cleveland Clinic, 9500 Euclid Ave., G10, Cleveland, OH, USA
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11
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Brodney S, Valentine KD, Vo HA, Cosenza C, Barry MJ, Sepucha KR. Measuring shared decision-making in younger and older adults with depression. Int J Qual Health Care 2022; 34:6717540. [PMID: 36161492 DOI: 10.1093/intqhc/mzac076] [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: 05/05/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This study examined the performance of the shared decision-making (SDM) Process scale in patients with depression, compared alternative wording of two items in the scale and explored performance in younger adults. METHODS A web-based non-probability panel of respondents with depression aged 18-39 (younger) or 40-75 (older) who talked with a health-care provider about starting or stopping treatment for depression in the past year were surveyed. Respondents completed one of two versions of the SDM Process scale that differed in the wording of pros and cons items and completed measures of decisional conflict, decision regret and who made the decision (mainly the respondent, mainly the provider or together). A subset of respondents completed a retest survey by 1 week. We examined how version and age group impacted SDM Process scores and calculated construct validity and retest reliability. We hypothesized that patients with higher SDM Process scores would show less decisional conflict using the SURE scale (range = 0-4); top score = no conflict versus other and less regret (range 1-4; higher scores indicated more regret). RESULTS The sample (N = 494) was majority White, non-Hispanic (82%) and female (72%), 48% were younger and 23% had a high school education or less. SDM Process scores did not differ by version (P = 0.09). SDM Process scores were higher for younger respondents (M = 2.6, SD = 1.0) than older respondents (M = 2.3, SD = 1.1; P = 0.001). Higher SDM Process scores were also associated with no decisional conflict (M = 2.6, SD = 0.99 vs. M = 2.1, SD = 1.2; P < 0.001) and less decision regret (r = -0.18, P < 0.001). Retest reliability was intraclass correlation coefficient = 0.81. CONCLUSIONS The SDM Process scale demonstrated validity and retest reliability in younger adults, and changes to item wording did not impact scores. Although younger respondents reported more SDM, there is room for improvement in SDM for depression treatment decisions.
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Affiliation(s)
- Suzanne Brodney
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114, USA
| | - K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - H A Vo
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114, USA
| | - Carol Cosenza
- Center for Survey Research, University of Massachusetts, Boston - 100 Morrissey Blvd, Boston, MA 02125, USA
| | - Michael J Barry
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Karen R Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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12
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Attanasio LB, Ranchoff BL, Paterno MT, Kjerulff KH. Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum. J Womens Health (Larchmt) 2022; 31:1411-1421. [PMID: 36067084 PMCID: PMC9618378 DOI: 10.1089/jwh.2021.0643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: Person-centered care has been increasingly recognized as an important aspect of health care quality, including in maternity care. Little is known about correlates and outcomes of person-centered care in maternity care in the United States. Materials and Methods: Data were from a prospective cohort of more than 3000 individuals who gave birth to a first baby in a Pennsylvania hospital. Person-centered maternity care was measured via a 13-item rating scale administered 1-month postpartum. Content validity was established through exploratory factor analysis. The resulting scale had scores ranging from 13 to 54, with Cronbach's alpha of 0.86. Using linear and logistic regression models to control for covariates, we examined associations between participants' characteristics and person-centered maternity care and between person-centered maternity care and postpartum outcomes. Results: Participants had a mean total score of 47.80 on the person-centered maternity care scale. Patient factors independently associated with more person-centered maternity care included older age, more positive attitude toward vaginal birth during pregnancy, and spontaneous vaginal birth. In adjusted models, higher person-centered maternity scale scores were strongly associated with many positive physical and mental health outcomes at 1 and 6 months postpartum. Conclusions: Our findings underscore the importance of person-centered maternity not just due to its intrinsic value but also because it may be associated with both mental and physical health outcomes through the postpartum period. Results suggest that policy efforts are necessary to ensure person-centered maternity care, especially for delivery hospitalization experience.
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Affiliation(s)
- Laura B. Attanasio
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Brittany L. Ranchoff
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Mary T. Paterno
- Cooley Dickinson ObGyn and Midwifery, Cooley Dickinson Medical Group, Northampton, Massachusetts, USA
| | - Kristen H. Kjerulff
- Department of Public Health Sciences and Penn State College of Medicine, Hershey, Pennsylvania, USA
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania, USA
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13
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Cole A, Richardson DR, Adapa K, Khasawneh A, Crossnohere N, Bridges JFP, Mazur L. Development of a Patient-Centered Preference Tool for Patients With Hematologic Malignancies: Protocol for a Mixed Methods Study. JMIR Res Protoc 2022; 11:e39586. [PMID: 35767340 PMCID: PMC9280452 DOI: 10.2196/39586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The approval of novel therapies for patients diagnosed with hematologic malignancies have improved survival outcomes but increased the challenge of aligning chemotherapy choices with patient preferences. We previously developed paper versions of a discrete choice experiment (DCE) and a best-worst scaling (BWS) instrument to quantify the treatment outcome preferences of patients with hematologic malignancies to inform shared decision making. OBJECTIVE We aim to develop an electronic health care tool (EHT) to guide clinical decision making that uses either a BWS or DCE instrument to capture patient preferences. The primary objective of this study is to use both qualitative and quantitative methods to evaluate the perceived usability, cognitive workload (CWL), and performance of electronic prototypes that include the DCE and BWS instrument. METHODS This mixed methods study includes iterative co-design methods that will involve healthy volunteers, patient-caregiver pairs, and health care workers to evaluate the perceived usability, CWL, and performance of tasks within distinct prototypes. Think-aloud sessions and semistructured interviews will be conducted to collect qualitative data to develop an affinity diagram for thematic analysis. Validated assessments (Post-Study System Usability Questionnaire [PSSUQ] and the National Aeronautical and Space Administration's Task Load Index [NASA-TLX]) will be used to evaluate the usability and CWL required to complete tasks within the prototypes. Performance assessments of the DCE and BWS will include the evaluation of tasks using the Single Easy Questionnaire (SEQ), time to complete using the prototype, and the number of errors. Additional qualitative assessments will be conducted to gather participants' feedback on visualizations used in the Personalized Treatment Preferences Dashboard that provides a representation of user results after completing the choice tasks within the prototype. RESULTS Ethical approval was obtained in June 2021 from the Institutional Review Board of the University of North Carolina at Chapel Hill. The DCE and BWS instruments were developed and incorporated into the PRIME (Preference Reporting to Improve Management and Experience) prototype in early 2021 and prototypes were completed by June 2021. Heuristic evaluations were conducted in phase 1 and completed by July 2021. Recruitment of healthy volunteers began in August 2021 and concluded in September 2021. In December 2021, our findings from phase 2 were accepted for publication. Phase 3 recruitment began in January 2022 and is expected to conclude in September 2022. The data analysis from phase 3 is expected to be completed by November 2022. CONCLUSIONS Our findings will help differentiate the usability, CWL, and performance of the DCE and BWS within the prototypes. These findings will contribute to the optimization of the prototypes, leading to the development of an EHT that helps facilitate shared decision making. This evaluation will inform the development of EHTs to be used clinically with patients and health care workers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39586.
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Affiliation(s)
- Amy Cole
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel R Richardson
- University of North Carolina Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Karthik Adapa
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amro Khasawneh
- Industrial Engineering Department, School of Engineering, Mercer University, Macon, GA, United States
| | - Norah Crossnohere
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Lukasz Mazur
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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14
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Mulé CM, Sliwinski SK, Israel R, Lavelle TA. Developmental Behavioral Pediatrician Perspectives on Decision-Making in Early Treatment Planning for Children with Autism Spectrum Disorder. J Dev Behav Pediatr 2022; 43:71-79. [PMID: 34654040 DOI: 10.1097/dbp.0000000000001002] [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: 10/02/2020] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Providers of children with autism spectrum disorder (hereafter "autism") report higher levels of shared decision-making during initial diagnostic and treatment planning visits than observed. The goal of this study was to qualitatively explore this discrepancy by investigating provider perceptions of the parent-provider decision-making process in early treatment planning and the role for parents in this process. METHODS We conducted semistructured qualitative interviews with developmental behavioral pediatricians (DBPs; n = 15) to investigate how they approach early treatment planning with parents. We analyzed participant characteristics using descriptive statistics. Interviews were audio-recorded, transcribed, and independently coded by 2 researchers until consensus was reached. Analyses were conducted using a modified grounded theory framework. RESULTS DBPs reported that their primary role during early treatment planning was to provide diagnostic clarification and that parents' primary role was to learn as much as they can about autism. Most DBPs wanted treatment planning to be collaborative, and perceived that parents had the same preference but might not have the knowledge or skills to effectively participate. DBPs identified additional barriers that influence the extent to which they engage parents in the collaborative decision-making and provided recommendations for enhancing the process. CONCLUSION DBPs are proponents of collaborative treatment planning between parents and providers; however, there are many obstacles that prevent this. Strategies such as decision tools or aids and larger systemic reforms are necessary to support DBPs and parents in this process.
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Affiliation(s)
- Christina M Mulé
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Tufts Children's Hospital, Tufts University School of Medicine, Boston, MA
| | | | - Rebecca Israel
- Master of Public Health Program, Tufts University School of Medicine, Boston, MA
| | - Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
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15
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Kassouf V, Sagherian BH, Yassin K, Antoun J. Effect of a discordant opinion offered by a second opinion physician on the patient's decision for management of spinal disc disease. PATIENT EDUCATION AND COUNSELING 2022; 105:228-232. [PMID: 33985847 DOI: 10.1016/j.pec.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Factors that influence a patient's decision for spinal surgery and selection of the spine surgeon have not been studied in the context of a Second Opinion (SO). Providing insight into these factors will guide surgeons in their discussion of treatment options with patients. OBJECTIVE This study aims to assess the impact of a discordant SO on the final decision of patients as compared to their initial preference regarding spinal disc disease treatment for chronic neck and low back pain. PATIENT INVOLVEMENT Patients in this study engage in clinical vignettes designed to induce decisional conflict. METHODS A cross-sectional study using clinical vignette-based questionnaires was presented to patients at the Family Medicine, Orthopedic, and Neurosurgery clinics at a university-based tertiary academic medical center. RESULTS A total of 246 patients participated in the study (response rate, 66.8%). Irrespective of the initial offered treatment, most patients wanted to consult a SO (64.2%). Most patients preferred conservative treatment to surgery after getting the initial recommendation (78.5%) and after getting a discordant SO (56.5%). There was an association between the agreement of the patient with the initial recommendation and the effect of the SO on the final decision of patients (p < 0.001). Patients who disagreed with the initially offered treatment were more likely to abide by their initial decision after the SO (80.8%) as compared to those who were in agreement (17.7%), while those who agreed with the initially offered treatment were more likely to change their decision (39.5%) or to take a third opinion (42.9%). DISCUSSION A discordant SO may validate patients' wishes when they disagree with the initially offered treatment and may lead to confusion when they agree with the initial physicians' recommendations. PRACTICAL VALUE As patients tend to abide by their initial preference, physicians should explicitly consider patients' wishes when discussing options for management of spinal disc disease.
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Affiliation(s)
- Vicky Kassouf
- Department of Family Medicine, American University of Beirut, Lebanon
| | - Bernard H Sagherian
- Division of Orthopedic Surgery / Department of Surgery, American University of Beirut, Lebanon
| | - Koumail Yassin
- Department of Arts and Science, American University of Beirut, Lebanon
| | - Jumana Antoun
- Department of Family Medicine, American University of Beirut, Lebanon.
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16
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Fowler FJ, Sepucha KR, Stringfellow V, Valentine KD. Validation of the SDM Process Scale to Evaluate Shared Decision-Making at Clinical Sites. J Patient Exp 2021; 8:23743735211060811. [PMID: 34869847 PMCID: PMC8640277 DOI: 10.1177/23743735211060811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Shared Decision-Making (SDM) Process scale (scored 0-4) uses 4 questions about decision-making behaviors: discussion of options, pros, cons, and preferences. We use data from mail surveys of patients who made surgical decisions at 9 clinical sites and a national web survey to assess the reliability and validity of the measure to assess shared decision-making at clinical sites. Patients at sites using decision aids to promote shared decision-making for hip, knee, back, or breast cancer surgery had significantly higher scores than national cross-section samples of surgical patients for 3 of 4 comparisons and significantly higher scores for both comparisons with “usual care sites.” Reliability was supported by an intra-class correlation at the clinical site level of 0.93 and an average correlation of SDM scores for knee and hip surgery patients treated at the same sites of 0.56. The results document the reliability and validity of the measure to assess the degree of shared decision-making for surgical decisions at clinical sites.
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Affiliation(s)
- Floyd J Fowler
- Center for Survey Research, University of Massachusetts Boston, Boston, USA
| | - Karen R Sepucha
- Harvard University School of Medicine, Cambridge, MA, USA.,Health Decisions Sciences Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - K D Valentine
- Health Decisions Sciences Center, Massachusetts General Hospital, Boston, MA, USA
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17
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Spratt DE, Shore N, Sartor O, Rathkopf D, Olivier K. Treating the patient and not just the cancer: therapeutic burden in prostate cancer. Prostate Cancer Prostatic Dis 2021; 24:647-661. [PMID: 33603236 PMCID: PMC8384628 DOI: 10.1038/s41391-021-00328-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prostate cancer (PC) is a leading cause of death in older men. Androgen deprivation therapy (ADT) is considered the standard-of-care for men with locally advanced disease. However, continuous androgen ablation is associated with acute and long-term adverse effects and most patients will eventually develop castration-resistant PC (CRPC). The recent approval of three, second-generation androgen receptor inhibitors (ARIs), apalutamide, enzalutamide, and darolutamide, has transformed the treatment landscape of PC. Treatment with these second-generation ARIs have produced positive trends in metastasis-free survival, progression-free survival, and overall survival. For patients with non-metastatic CRPC, who are mainly asymptomatic from their disease, maintaining quality of life is a major objective when prescribing therapy. Polypharmacy for age-related comorbidities also is common in this population and may increase the potential for drug-drug interactions (DDIs). METHOD This review summarizes the multiple factors that may contribute to the therapeutic burden of patients with CRPC, including the interplay between age, comorbidities, concomitant medications, the use of ARIs, and financial distress. CONCLUSIONS As the treatment landscape in PC continues to rapidly evolve, consideration must be given to the balance between therapeutic benefits and potential treatment-emergent adverse events that may be further complicated by DDIs with concomitant medications. Patient-centered communication is a crucial aspect of alleviating this burden, and healthcare professionals (HCPs) may benefit from training in effective patient communication. HCPs should closely and frequently monitor patient treatment responses, in order to better understand symptom onset and exacerbation. Patients also should be encouraged to participate in exercise programs, and health information and support groups, which may assist them in preventing or mitigating certain determinants of the therapeutic burden associated with PC and its management.
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Affiliation(s)
| | - Neal Shore
- Carolina Urologic Research Center, Atlantic Urology Clinics, Myrtle Beach, SC, USA
| | - Oliver Sartor
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Dana Rathkopf
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kara Olivier
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
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18
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Valentine KD, Mancini B, Vo H, Brodney S, Cosenza C, Barry MJ, Sepucha KR. Using Standardized Videos to Examine the Validity of the Shared Decision Making Process Scale: Results of a Randomized Online Experiment. Med Decis Making 2021; 42:105-113. [PMID: 34344233 DOI: 10.1177/0272989x211029267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Shared Decision Making (SDM) Process scale is a brief, patient-reported measure of SDM with demonstrated validity in surgical decision making studies. Herein we examine the validity of the scores in assessing SDM for cancer screening and medication decisions through standardized videos of good-quality and poor-quality SDM consultations. METHOD An online sample was randomized to a clinical decision-colon cancer screening or high cholesterol-and a viewing order-good-quality video first or poor-quality video first. Participants watched both videos, completing a survey after each video. Surveys included the SDM Process scale and the 9-item SDM Questionnaire (SDM-Q-9); higher scores indicated greater SDM. Multilevel linear regressions identified if video, order, or their interaction predicted SDM Process scores. To identify how the SDM Process score classified videos, area under the curve (AUC) was calculated. The correlation between SDM Process score and SDM-Q-9 assessed construct validity. Heterogeneity analyses were conducted. RESULTS In the sample of 388 participants (68% white, 70% female, average age 45 years) good-quality videos received higher SDM Process scores than poor-quality videos (Ps < 0.001), and those who viewed the good-quality high cholesterol video first tended to rate the videos higher. SDM Process scores were related to SDM-Q-9 scores (rs > 0.58; Ps < 0.001). AUC was poor (0.69) for the high cholesterol model and fair (0.79) for the colorectal cancer model. Heterogeneity analyses suggested individual differences were predictive of SDM Process scores. CONCLUSION SDM Process scores showed good evidence of validity in a hypothetical scenario but were lacking in ability to classify good-quality or poor-quality videos accurately. Considerable heterogeneity of scoring existed, suggesting that individual differences played a role in evaluating good- or poor-quality SDM conversations.
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Affiliation(s)
- K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Brittney Mancini
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ha Vo
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne Brodney
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carol Cosenza
- Center for Survey Research, University of Massachusetts, Boston, Boston, MA, USA
| | - Michael J Barry
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Karen R Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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19
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DuBenske L, Ovsepyan V, Little T, Schrager S, Burnside E. Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter. J Patient Exp 2021; 8:23743735211034039. [PMID: 34377770 PMCID: PMC8326620 DOI: 10.1177/23743735211034039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: The US Preventative Services Task Force recommends shared decision-making (SDM) between women aged 40 and 49 years and their physician regarding timing of mammography screening. This preliminary study evaluates women’s and physician’s satisfaction using Breast Cancer Risk Estimator & Decision Aid (BCARE-DA), a shared decision aid utilized during the clinical encounter, and examines SDM quality for these encounters. Methods: Fifty-three women and their physician utilized BCARE-DA and completed surveys measuring satisfaction with Likert-type and open-ended items and women completed the Decision Conflict Scale. Clinic visit transcripts were evaluated for SDM quality using Observer OPTION-5 and Breast Cancer Screening Decision Core Components Checklist. Results: Women and physicians positively evaluated BCARE-DA. Women had low decision conflict. Physicians demonstrated moderate effort toward SDM, greatest in offering options, and lowest for team talk. Physicians demonstrated 2/3 of core SDM elements in 80% to 100% of encounters. Conclusion: Preliminary findings suggest specific promise for such Decision Aids to facilitate SDM through understanding of personal risks for breast cancer formulated within each screening option, while some SDM elements likely require additional facilitating.
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Affiliation(s)
- Lori DuBenske
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA
| | - Viktoriya Ovsepyan
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, USA
| | - Terry Little
- Department of Radiology, University of Wisconsin, Madison, WI, USA
| | - Sarina Schrager
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, USA
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20
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Wagle AA, Isakadze N, Nasir K, Martin SS. Strengthening the Learning Health System in Cardiovascular Disease Prevention: Time to Leverage Big Data and Digital Solutions. Curr Atheroscler Rep 2021; 23:19. [PMID: 33693992 DOI: 10.1007/s11883-021-00916-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The past few decades have seen significant technologic innovation for the treatment and diagnosis of cardiovascular diseases. The subsequent growing complexity of modern medicine, however, is causing fundamental challenges in our healthcare system primarily in the spheres of patient involvement, data generation, and timely clinical implementation. The Institute of Medicine advocated for a learning health system (LHS) in which knowledge generation and patient care are inherently symbiotic. The purpose of this paper is to review how the advances in technology and big data have been used to further patient care and data generation and what future steps will need to occur to develop a LHS in cardiovascular disease. RECENT FINDINGS Patient-centered care has progressed from technologic advances yielding resources like decision aids. LHS can also incorporate patient preferences by increasing and standardizing patient-reported information collection. Additionally, data generation can be optimized using big data analytics by developing large interoperable datasets from multiple sources to allow for real-time data feedback. Developing a LHS will require innovative technologic solutions with a patient-centered lens to facilitate symbiosis in data generation and clinical practice.
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Affiliation(s)
- Anjali A Wagle
- Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Harvey Building, Suite 808, Baltimore, MD, 21287, USA.
| | - Nino Isakadze
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khurram Nasir
- Division of Cardiology, Houston Methodist Hospital, Houston, TX, USA
| | - Seth Shay Martin
- Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Harvey Building, Suite 808, Baltimore, MD, 21287, USA.,Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Fowler FJ, Barry MJ, Sepucha KR, Moulton BW. Let's Require Patients to Review a High-quality Decision Aid Before Receiving Important Tests and Treatments. Med Care 2021; 59:1-5. [PMID: 33136712 PMCID: PMC7737866 DOI: 10.1097/mlr.0000000000001440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Michael J. Barry
- Informed Medical Decisions Program, MGH Division of General Internal Medicine
| | - Karen R. Sepucha
- Health Decision Sciences Center, Massachusetts General Hospital, Boston
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22
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McDow AD, Roman BR, Saucke MC, Jensen CB, Zaborek N, Jennings JL, Davies L, Brito JP, Pitt SC. Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer. Am J Surg 2020; 222:111-118. [PMID: 33248684 DOI: 10.1016/j.amjsurg.2020.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC. METHODS We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS). RESULTS The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS. CONCLUSIONS Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.
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Affiliation(s)
- Alexandria D McDow
- Division of Surgery Oncology, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive EH 537, Indianapolis, IN, 46202, USA.
| | - Benjamin R Roman
- Division of Head and Neck, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Catherine B Jensen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Nick Zaborek
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Jamia Linn Jennings
- Wisconsin Department of Health Services, 1 West Wilson Street, Madison, WI, 53703, USA.
| | - Louise Davies
- The VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, USA and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
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23
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Rencz F, Tamási B, Brodszky V, Ruzsa G, Gulácsi L, Péntek M. Did You Get What You Wanted? Patient Satisfaction and Congruence Between Preferred and Perceived Roles in Medical Decision Making in a Hungarian National Survey. Value Health Reg Issues 2020; 22:61-67. [PMID: 32798836 DOI: 10.1016/j.vhri.2020.07.573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/21/2020] [Accepted: 07/02/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVES In a growing number of countries, patient involvement in medical decisions is considered a cornerstone of broader health policy agendas. This study seeks to explore public preferences for and experiences with participation in treatment decisions in Hungary. METHODS A nationally representative online panel survey was conducted in 2019. Outcome measures included the Control Preferences Scale for the preferred and actual role in the decision, the 9-item Shared Decision Making Questionnaire, and a Satisfaction With Decision numeric rating scale. RESULTS A total of 1000 respondents participated in the study, 424 of whom reported having had a treatment decision in the preceding 6 months. Overall, 8%, 18%, 51%, 19%, and 4% of the population preferred an active, semiactive, shared, semipassive, and passive role in decision making, respectively. Corresponding rates for perceived role were as follows: 9%, 15%, 35%, 26%, and 15%. Preferred and perceived roles matched for 52% of the population, whereas 32% preferred more and 16% less participation. Better health status, attaining role congruence, and higher 9-item Shared Decision Making Questionnaire scores were positively associated with satisfaction, accounting for 32% of the variation in Satisfaction With Decision scores (P < .05). CONCLUSIONS This study represents the first national survey on decisional roles in healthcare in Hungary and, more broadly, in Central and Eastern Europe. Shared decision making is the most preferred decisional role in Hungary; nevertheless, there is still room to improve patient involvement in decision making. It seems that patient satisfaction may be improved through tailoring the decisional role to reflect patients' preferences and through practices that encourage shared decision making.
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Affiliation(s)
- Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary; Premium Postdoctoral Research Programme, Hungarian Academy of Sciences, Budapest, Hungary.
| | - Béla Tamási
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - Gábor Ruzsa
- Institute of Psychology, Doctoral School of Psychology, Eötvös Loránd University of Sciences, Budapest, Hungary; Department of Statistics, Corvinus University of Budapest, Budapest, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
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Howren MB, Vander Weg MW, Christensen AJ, Kaboli PJ. Association of patient preferences on medication discussion in hypertension: Results from a randomized clinical trial. Soc Sci Med 2020; 262:113244. [PMID: 32750626 DOI: 10.1016/j.socscimed.2020.113244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/26/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]
Abstract
Patient-centered care has received significant attention and is an integral component of high-quality healthcare. While it is often assumed that most prefer a patient-centered role orientation, such preferences exist along a continuum with some patients preferring a more provider-centered role. The present study examines patient preference data from a randomized clinical trial designed to test the efficacy of a patient activation intervention to promote thiazide prescribing for veteran patients with uncontrolled hypertension. Patient preferences for involvement in healthcare were assessed using the 9-item Sharing subscale of the Patient-Practitioner Orientation Scale (PPOS). The primary aim was to examine differences in discussion of thiazide use in the clinical encounter by those scoring high versus low on the PPOS. Five hundred ninety-five veteran patients were randomized to either one of three intervention groups or a usual care control group. The adjusted odds ratios (OR) for the three intervention groups relative to the control group indicated that thiazide discussion increased as a function of intervention intensity across both high and low PPOS groups. ORs for the most intensive intervention group were 3.72 (95% CI = 1.61-8.65, p < .01) for high PPOS patients and 6.71 (95% CI = 2.59-10.67, p < .001) for low PPOS patients. Results suggest that this patient activation intervention is effective for veteran patients representing a range of preferred involvement. Consideration of such preferences may be useful in tailoring future interventions in the healthcare context.
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Affiliation(s)
- M Bryant Howren
- Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Department of Behavioral Sciences & Social Medicine, College of Medicine, Florida State University, Tallahassee, FL, USA.
| | - Mark W Vander Weg
- Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Division of General Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Psychological & Brain Sciences, The University of Iowa, Iowa City, IA, USA
| | | | - Peter J Kaboli
- Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Division of General Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Core Elements of Shared Decision-making for Women Considering Breast Cancer Screening: Results of a Modified Delphi Survey. J Gen Intern Med 2020; 35:1668-1677. [PMID: 32193817 PMCID: PMC7280383 DOI: 10.1007/s11606-019-05298-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 06/07/2019] [Accepted: 07/30/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND The United States Preventive Services Task Force recommends individualized breast cancer screening for average-risk women before age 50, advised by risk assessment and shared decision-making (SDM). However, the foundational principles of this recommendation that would inform decision support tools for patients and primary care physicians at the point of care have not been codified. Determining the core elements of SDM for breast cancer screening as valued by patients and primary care providers (PCPs) is necessary for implementing effective SDM tools. The aim of this study is to affirm core elements of SDM in the context of clinical interactions, through a Delphi consensus process. METHODS A Delphi was conducted with 30 participants (10 women aged 40-49, 10 PCPs, and 10 healthcare decision scientists), to codify core elements of breast cancer screening SDM. The criterion for establishing consensus was a threshold of 80% agreement. The Delphi concluded with an 83% response rate. RESULTS Of 48 items fielded, 44 met the threshold on the high-importance end of the response scale and were accepted as core elements. Core elements across three thematic categories-information delivery and patient education, interpersonal clinician-patient communication, and framework of the decision-received panelists' support in nearly equal measure. Panelists unanimously agreed that SDM should include provision of clearly understandable information, including that of personal breast cancer risk factors, and benefits and harms of mammography screening, and that PCPs should convey they are listening, knowledgeable, and demonstrate cultural sensitivity. DISCUSSION This research codifies the core elements of SDM for mammography in women 40-49, augmenting the evidence to inform discussions between patients and physicians. These core elements of SDM have the potential to operationalize SDM for breast cancer screening in an effort to improve public health outcomes.
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Shared decision making about blood tests: secondary analysis of video-recorded primary care consultations. Br J Gen Pract 2020; 70:e339-e347. [PMID: 32312760 DOI: 10.3399/bjgp20x709409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/09/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Awareness of the importance of shared decision making (SDM) is widespread; however, little research has focused on discussions surrounding investigations, despite increasing laboratory testing in primary care. AIM To explore the discussion of blood tests in routine primary care consultations. DESIGN AND SETTING A secondary analysis of 50 video-recorded routine primary care consultations, linked surveys, and records data (all from the One in a Million [OiaM] archive). The consultations were taken by 22 GPs across 12 practices. METHOD A coding scheme was developed, using qualitative content analysis, to explore discussion of blood tests in transcripts of recorded consultations. Codes focused on instigating testing, the extent of SDM, and how results were explained. Survey data were used to compare patients' pre-visit expectations with consultation content. Medical records were reviewed to compare tests discussed with those ordered. RESULTS In 36 out of 50 consultations that discussed ordering blood tests, 11 patients (31%) hinted that they wanted a blood test; however, none asked explicitly. Only four patients (11%) were offered alternative options. In 29 cases (81%) the GP gave some explanation of the indication, but only in six cases (17%) were the limitations of testing explained. Only 10 out of 31 patients (32%) were informed about all blood tests ordered. Of the 23 out of 50 consultations in which results were conveyed, the GP gave no explanation of the results in six cases (26%). Thirteen patients (57%) were only informed of an assessment of the results (for example, 'normal'), rather than the actual results. CONCLUSION A lack of information dissemination and SDM exists around ordering tests and conveying results. Promoting SDM could reduce unnecessary testing and improve patient-centred care.
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Malhotra C, Kanesvaran R, Barr Kumarakulasinghe N, Tan SH, Xiang L, Tulsky JA, Pollak KI. Oncologist-patient-caregiver decision-making discussions in the context of advanced cancer in an Asian setting. Health Expect 2019; 23:220-228. [PMID: 31682064 PMCID: PMC6978867 DOI: 10.1111/hex.12994] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022] Open
Abstract
Objective Patient involvement in treatment decisions is recommended in clinician‐patient encounters. Little is known about how oncologists engage patients in shared decision making in non‐Western countries. We assessed the prevalence of shared decision making among Singaporean oncologists and analysed how they discussed prognosis. Methods We audio‐recorded 100 consultations between advanced cancer patients and their oncologists. We developed a coding system to assess oncologist encouragement of patient participation in decision making and disclosure of an explicit prognosis. We assessed patient and oncologist characteristics that predicted these behaviours. Results Forty‐one consultations involved treatment discussions. Oncologists almost always listed more than one treatment option (90%). They also checked patient understanding (34%), discussed pros and cons (34%) and addressed uncertainty (29%). Oncologists discussed prognosis mostly qualitatively (34%) rather than explicitly (17%). They were more likely to give an explicit prognosis when patients/caregivers asked questions related to prognosis. Conclusion Oncologists in our sample engaged their patients in decision making. They have areas in which they can improve to involve patients at a deeper level to ensure shared decision making. Findings will be used to develop an intervention targeting oncologists and patients to promote patient involvement in decision making.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | | | | | - Sing-Huang Tan
- OncoCare Cancer Centre, Gleneagles Medical Centre, Singapore, Singapore
| | - Ling Xiang
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - James A Tulsky
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Kathryn I Pollak
- Cancer Control and Population Sciences, Duke University, Durham, NC, USA.,Population Health Sciences, Duke University, Durham, NC, USA
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Rencz F, Tamási B, Brodszky V, Gulácsi L, Weszl M, Péntek M. Validity and reliability of the 9-item Shared Decision Making Questionnaire (SDM-Q-9) in a national survey in Hungary. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:43-55. [PMID: 31111402 PMCID: PMC6544590 DOI: 10.1007/s10198-019-01061-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 04/14/2019] [Indexed: 05/15/2023]
Abstract
BACKGROUND The nine-item Shared Decision Making Questionnaire (SDM-Q-9) is one of the most frequently applied instruments for assessing patients' involvement in medical decision-making. Our objectives were to develop a Hungarian version of SDM-Q-9, to evaluate its psychometric properties and to compare its performance between primary and specialised care settings. METHODS In 2019, a sample of adults (n = 537) representative of the Hungarian general population in terms of age, gender and geographic region completed an online survey with respect to a recent health-related decision. Outcome measures included SDM-Q-9 and Control Preferences Scale-post (CPSpost). Item characteristics, internal consistency reliability and the factor structure of SDM-Q-9 were determined. RESULTS The overall ceiling and floor effects for SDM-Q-9 total scores were 12.3% and 2.2%, respectively. An excellent internal consistency reliability (Cronbach's alpha 0.925) was demonstrated. Exploratory factor analysis resulted in a one-factor model explaining 63.5% of the variance of SDM-Q-9. A confirmatory factor analysis supported the acceptability of this model. Known-groups validity was confirmed with CPSpost categories; mean SDM-Q-9 total scores were higher in the 'Shared decision' category (72.6) compared to both 'Physician decided' (55.1, p = 0.0002) and 'Patient decided' (57.2, p = 0.0086) categories. In most aspects of validity and reliability, there was no statistically significant difference between primary and specialised care. CONCLUSIONS The overall good measurement properties of the Hungarian SDM-Q-9 make the questionnaire suitable for use in both primary and specialised care settings. SDM-Q-9 may be useful for health policies targeting the implementation of shared decision-making and aiming to improve efficiency and quality of care in Hungary.
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Affiliation(s)
- Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, Budapest, 1093, Hungary.
- Premium Postdoctoral Research Programme, Hungarian Academy of Sciences, Nádor u. 7, Budapest, 1051, Hungary.
| | - Béla Tamási
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Mária u. 41, Budapest, 1085, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, Budapest, 1093, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, Budapest, 1093, Hungary
| | - Miklós Weszl
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, Budapest, 1093, Hungary
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, Budapest, 1093, Hungary
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Grande SW, O'Neill ES, Sherman AE, Coylewright M. Are Older Adults Willing to Consider New Strategies to Reduce Stroke Risk? QUALITATIVE HEALTH RESEARCH 2019; 29:568-576. [PMID: 28985686 DOI: 10.1177/1049732317720682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Atrial fibrillation (AF) is a common arrhythmia that increases patients' risk of stroke, and determining an optimal prevention therapy is a preference-sensitive decision appropriate for shared decision making (SDM). Utilizing community-based focus groups, we explored beliefs and values around options for stroke prevention. Interview transcripts from five independent focus groups were qualitatively assessed and organized into themes. Most participants were taking a blood thinner (93%) and more than half of participants (64%) reported having AF. Few participants were familiar with newer therapies. Qualitative analysis revealed three themes: (a) fearing loss of self-control through debilitating stroke, (b) recognizing uncertainty in how to weigh risks and benefits of new treatments, and (c) needing mutual respect between clinicians and patients to consider new/alternative treatment regimens. These findings help direct future research efforts examining optimal timing for SDM and decision aids to promote mutual respect.
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Affiliation(s)
- Stuart W Grande
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | | | - Ariel E Sherman
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Megan Coylewright
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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DuBenske LL, Schrager SB, Hitchcock ME, Kane AK, Little TA, McDowell HE, Burnside ES. Key Elements of Mammography Shared Decision-Making: a Scoping Review of the Literature. J Gen Intern Med 2018; 33:1805-1814. [PMID: 30030738 PMCID: PMC6153221 DOI: 10.1007/s11606-018-4576-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/29/2018] [Accepted: 07/03/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND New guidelines recommend shared decision-making (SDM) for women and their clinician in consideration of breast cancer screening, particularly for women ages 35-50 where guidelines for routine mammography are controversial. A number of models offer general guidelines for SDM across clinical practice, yet they do not offer specific guidance about conducting SDM in mammography. We conducted a scoping review of the literature to identify the key elements of breast cancer screening SDM and synthesize these key elements for utilization by primary care clinicians. METHODS The Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus); PsycInfo, PubMed (MEDLINE), Scopus, and SocIndex databases were searched. Inclusion criteria were original studies from peer-reviewed publications (from 2009 or later) reporting breast cancer screening (mammography), medical decision-making, and patient-centered care. Study populations needed to include female patients 18+ years of age facing a real-life breast cancer screening decision. Article findings were specific to shared decision-making and/or use of a decision aid. Data extracted includes study design, population, setting, intervention, and critical findings related to breast cancer screening SDM elements. Scoping analysis includes descriptive analysis of study features and content analysis to identify the SDM key elements. RESULTS Twenty-four articles were retained. Three thematic categories of key elements emerged from the extracted elements: information delivery/patient education (specific content and delivery modes), interpersonal clinician-patient communication (aspects of interpersonal relationship impacting SDM), and framework of the decision (sociocultural factors beyond direct SDM deliberation). A number of specific breast cancer screening SDM elements relevant to primary care clinical practice are delineated. DISCUSSION The findings underscore the importance of the relationship between the patient and clinician and the necessity of spelling out each step in the SDM process. The clinician needs to be explicit in telling a woman that she has a choice about whether to get a mammogram and the benefits and harms of screening mammography. Finally, clinicians need to be aware of sociocultural factors that can influence their relationships and their patients' decision-making processes and attempt to identify and address these factors.
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Affiliation(s)
- Lori L DuBenske
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
| | - Sarina B Schrager
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Mary E Hitchcock
- Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Amanda K Kane
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Terry A Little
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Elizabeth S Burnside
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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31
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Declercq ER, Cheng ER, Sakala C. Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia? Birth 2018; 45:236-244. [PMID: 29934981 DOI: 10.1111/birt.12365] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/18/2018] [Accepted: 05/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions. METHODS Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean. RESULTS Almost half (N = 163; 47%) of women who were told their baby might be large reported engaging in a discussion concerning possible labor induction vs waiting for labor, while a large majority (N = 321; 82%) of women with a prior cesarean discussed the option of a repeat cesarean or a planned vaginal birth after cesarean (VBAC). Women who engaged in discussions received disproportionate information about having the interventions and were more likely to experience the interventions (68% induction, 87% repeat cesarean) than women who did not. After adjustment, women who reported that their provider recommended scheduling a repeat cesarean were 14 times more likely to give birth via cesarean compared with those whose providers recommended planning VBAC (AOR 14.2; 95% CI: 3.2, 63.0). CONCLUSION Our findings suggest that, for the decisions in question, established standards of shared decision-making are not being reliably implemented in maternity care despite opportunities to do so. Provider recommendations and the disproportionate conveyance of reasons for an intervention appear to be related to higher levels of intervention.
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Affiliation(s)
- Eugene R Declercq
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Erika R Cheng
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carol Sakala
- National Partnership for Women and Families, Washington, DC, USA
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Wiener RS, Koppelman E, Bolton R, Lasser KE, Borrelli B, Au DH, Slatore CG, Clark JA, Kathuria H. Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study. J Gen Intern Med 2018; 33:1035-1042. [PMID: 29468601 PMCID: PMC6025674 DOI: 10.1007/s11606-018-4350-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/29/2017] [Accepted: 01/18/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings. OBJECTIVE To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making. DESIGN Qualitative study entailing semi-structured interviews and focus groups. PARTICIPANTS We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net). APPROACH Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making. KEY RESULTS Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making. CONCLUSIONS Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening's rationale, trade-offs, and process.
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Affiliation(s)
- Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA. .,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.
| | - Elisa Koppelman
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Rendelle Bolton
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA.,The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Karen E Lasser
- Boston University School of Public Health, Boston, MA, USA.,Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Belinda Borrelli
- Henry M. Goldman School of Dental Medicine, Boston University, Boston, MA, USA
| | - David H Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jack A Clark
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Hasmeena Kathuria
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
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Danesh V. Escalations in Care: Do Interhospital Transfers Lead to Greener Pastures? Crit Care Med 2018; 46:175-176. [PMID: 29252952 DOI: 10.1097/ccm.0000000000002823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Valerie Danesh
- University of Texas at Austin School of Nursing Austin, TX
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34
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Matlock DD, McGuire WC, Magid M, Allen L. Decision making in advanced heart failure: bench, bedside, practice, and policy. Heart Fail Rev 2018; 22:559-564. [PMID: 28670652 DOI: 10.1007/s10741-017-9631-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This is an exciting time for patient-centered care. The window of opportunity appears to be open for the medical culture to accept the importance of the patients' values, goals and preferences in guiding medical decisions. Heart failure guidelines are changing to include language around shared decision making for major procedures and end-of-life care. However, while the cultural norms appear to be moving in this direction, the science regarding how to best deliver patient centered care (basic, clinical, delivery, and policy) is still developing. This article will provide a broad overview of the science of decision making in advanced heart failure using a translational science framework.
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Affiliation(s)
- Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, 13199 E. Montview Blvd. Suite 210, Mail Stop F443, Aurora, CO, 80045, USA.
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA.
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, USA.
| | | | | | - Larry Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Herrmann A, Hall A, Sanson-Fisher R, Zdenkowski N, Watson R, Turon H. Not asking cancer patients about their preferences does make a difference. A cross-sectional study examining cancer patients' preferred and perceived role in decision-making regarding their last important cancer treatment. Eur J Cancer Care (Engl) 2018; 27:e12871. [PMID: 29900611 DOI: 10.1111/ecc.12871] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/04/2018] [Accepted: 05/05/2018] [Indexed: 11/26/2022]
Abstract
We examined whether not having been asked by their clinicians about how involved cancer patients would like to be in their treatment decisions is related to discordance between patients' preferred and perceived involvement in treatment decision-making. This was a cross-sectional survey of adult cancer patients recruited from five medical and radiation oncology outpatient clinics in Australia. Discordance of patients' preferred and perceived decision-making roles was assessed via an adapted version of the Control Preferences Scale. Logistic regression modelling was conducted to assess the relationship between role discordance and whether patients were not asked but wanted to be asked about how involved they would like to be in deciding on their treatment. Of 423 study participants, almost a third (n = 128, 31%) reported discordance between their preferred and perceived involvement in their treatment decisions. Of those reporting discordance, 72% (n = 92) were less involved than they would have liked to have been. Not being asked about their preferences for involvement in treatment decisions, despite wanting this, was associated with discordance between patients' preferred and perceived involvement in treatment decision-making (p < 0.04). To achieve patient-centred care, it is vital that clinicians seek patients' views about how involved they would like to be in deciding on their cancer treatment.
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Affiliation(s)
- Anne Herrmann
- Priority Research Centre for Health Behaviour, University of Newcastle/Hunter Medical Research Institute, Callaghan, NSW, Australia
| | - Alix Hall
- Priority Research Centre for Health Behaviour, University of Newcastle/Hunter Medical Research Institute, Callaghan, NSW, Australia
| | - Rob Sanson-Fisher
- Priority Research Centre for Health Behaviour, University of Newcastle/Hunter Medical Research Institute, Callaghan, NSW, Australia
| | - Nicholas Zdenkowski
- Department of Medical Oncology, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Rochelle Watson
- Priority Research Centre for Health Behaviour, University of Newcastle/Hunter Medical Research Institute, Callaghan, NSW, Australia
| | - Heidi Turon
- Priority Research Centre for Health Behaviour, University of Newcastle/Hunter Medical Research Institute, Callaghan, NSW, Australia
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Slatore CG, Wiener RS. Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It. Chest 2018; 153:1004-1015. [PMID: 29066390 PMCID: PMC5989642 DOI: 10.1016/j.chest.2017.10.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/26/2017] [Accepted: 10/09/2017] [Indexed: 12/21/2022] Open
Abstract
Every year, millions of patients are diagnosed with pulmonary nodules, and as increasing numbers of people undergo lung cancer screening, even more patients will be found to have a nodule. The vast majority of patients cannot benefit from the detection of a pulmonary nodule because most are benign. Accordingly, it is important to develop strategies to minimize harm, in particular the distress of a "near-cancer" diagnosis. In other settings, communication strategies are critical mediators of patient-centered outcomes for those with cancer and those at-risk of cancer. We conducted multiple studies to characterize the experience of patients with the diagnosis and evaluation of incidental pulmonary nodules, measure patient-centered outcomes for patients with pulmonary nodules, and determine the association of patient-clinician communication practices with those outcomes. We learned that a substantial proportion of patients experience distress and inadequate communication about pulmonary nodules and their evaluation, and yet many clinicians are unaware of the degree to which some patients are affected by the finding of a pulmonary nodule. The present review provides a comprehensive summary of our results and offers suggestions for how clinicians can best provide high-quality communication for their patients.
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Affiliation(s)
- Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, Portland, OR; Division of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR.
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA
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Allen LA, McIlvennan CK, Thompson JS, Dunlay SM, LaRue SJ, Lewis EF, Patel CB, Blue L, Fairclough DL, Leister EC, Glasgow RE, Cleveland JC, Phillips C, Baldridge V, Walsh MN, Matlock DD. Effectiveness of an Intervention Supporting Shared Decision Making for Destination Therapy Left Ventricular Assist Device: The DECIDE-LVAD Randomized Clinical Trial. JAMA Intern Med 2018; 178:520-529. [PMID: 29482225 PMCID: PMC5876922 DOI: 10.1001/jamainternmed.2017.8713] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Shared decision making helps patients and clinicians elect therapies aligned with patients' values and preferences. This is particularly important for invasive therapies with considerable trade-offs. OBJECTIVE To assess the effectiveness of a shared decision support intervention for patients considering destination therapy left ventricular assist device (DT LVAD) placement. DESIGN, SETTING, AND PARTICIPANTS From 2015 to 2017, a randomized, stepped-wedge trial was conducted in 6 US LVAD implanting centers including 248 patients being considered for DT LVAD. After randomly varying time in usual care, sites were transitioned to an intervention consisting of clinician education and use of DT LVAD pamphlet and video patient decision aids. Follow up occurred at 1 and 6 months. MAIN OUTCOMES AND MEASURES Decision quality as measured by knowledge and values-choice concordance. RESULTS In total, 135 patients were enrolled during control and 113 during intervention periods. At enrollment, 59 (23.8%) participants were in intensive care, 60 (24.1%) were older than 70 years, 39 (15.7%) were women, 45 (18.1%) were racial/ethnic minorities, and 62 (25.0%) were college graduates. Patient knowledge (mean test performance) during the decision-making period improved from 59.5% to 64.9% in the control group vs 59.1% to 70.0% in the intervention group (adjusted difference of difference, 5.5%; P = .03). Stated values at 1 month (scale 1 = "do everything I can to live longer…" to 10 = "live with whatever time I have left…") were a mean of 2.37 in control and 3.33 in intervention (P = .03). Patient-reported treatment choice at 1 month favored LVAD more in the control group (than in the intervention group (47 [59.5%] vs 95 [91.3%], P < .001). Correlation between stated values and patient-reported treatment choice at 1 month was stronger in the intervention group than in the control group (difference in Kendall's τ, 0.28; 95% CI, 0.05-0.45); however, there was no improved correlation between stated values and actual treatment received by 6 months for the intervention compared with the control group (difference in Kendall's τ, 0.01; 95% CI, -0.24 to 0.25). The adjusted rate of LVAD implantation by 6 months was higher for those in the control group (79.9%) than those in the intervention group (53.9%, P = .008), with significant variation by site. There were no differences in decision conflict, decision regret, or preferred control. CONCLUSIONS AND RELEVANCE A shared decision-making intervention for DT LVAD modestly improved patient decision quality as measured by patient knowledge and concordance between stated values and patient-reported treatment choice, but did not improve concordance between stated values and actual treatment received. The rate of implantation of LVADs was substantially lower in the intervention compared with the control group. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02344576.
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Affiliation(s)
- Larry A Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Colleen K McIlvennan
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Jocelyn S Thompson
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Shannon M Dunlay
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Shane J LaRue
- Washington University School of Medicine, St Louis, Missouri
| | | | | | - Laura Blue
- Duke University Medical Center, Durham, North Carolina
| | - Diane L Fairclough
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora
| | - Erin C Leister
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora
| | - Russell E Glasgow
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Veterans Affairs, Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora
| | | | | | - Mary Norine Walsh
- Division of Cardiology, St Vincent Heart Center, Indianapolis, Indiana
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Veterans Affairs, Eastern Colorado Geriatric Research Education and Clinical Center, Denver.,Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora
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Laws MB, Lee Y, Taubin T, Rogers WH, Wilson IB. Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology. PLoS One 2018; 13:e0191940. [PMID: 29389994 PMCID: PMC5794108 DOI: 10.1371/journal.pone.0191940] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/13/2018] [Indexed: 11/30/2022] Open
Abstract
While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur. Our objective was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients 1 week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36% recalled with a prompt; 15% recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and “teach back,” were rare. Patients with less than high school education recalled 38% of items freely and accurately, while patients with a college degree recalled 65% (p < .0001). In a multivariate model, the total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider (“verbal dominance”), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.
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Affiliation(s)
- M. Barton Laws
- Brown University School of Public Health, Department of Health Services, Policy and Practice, Providence, Rhode Island, United States of America
- * E-mail:
| | - Yoojin Lee
- Brown University School of Public Health, Department of Health Services, Policy and Practice, Providence, Rhode Island, United States of America
| | - Tatiana Taubin
- Brown University School of Public Health, Department of Health Services, Policy and Practice, Providence, Rhode Island, United States of America
| | - William H. Rogers
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, United States of America
| | - Ira B. Wilson
- Brown University School of Public Health, Department of Health Services, Policy and Practice, Providence, Rhode Island, United States of America
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Woolf SH, Krist AH, Lafata JE, Jones RM, Lehman RR, Hochheimer CJ, Sabo RT, Frosch DL, Zikmund-Fisher BJ, Longo DR. Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal. Am J Prev Med 2018; 54:237-247. [PMID: 29241715 PMCID: PMC7144024 DOI: 10.1016/j.amepre.2017.10.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 10/03/2017] [Accepted: 10/30/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision. METHODS Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50-74 years who were overdue for colorectal cancer screening and to women aged 40-49 years and men aged 55-69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively. RESULTS The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05). CONCLUSIONS Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.
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Affiliation(s)
- Steven H Woolf
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia.
| | - Alex H Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Jennifer Elston Lafata
- Department of Health Behavior and Policy, Lineberger Comprehensive Cancer Center and Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Resa M Jones
- Department of Epidemiology and Biostatistics, Temple University, Philadelphia, Pennsylvania
| | | | - Camille J Hochheimer
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Dominick L Frosch
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Daniel R Longo
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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40
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St Clair Russell J, Boulware LE. End-stage renal disease treatment options education: What matters most to patients and families. Semin Dial 2018; 31:122-128. [PMID: 29315798 DOI: 10.1111/sdi.12665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Treatment modality education can offer many important benefits to patients and their families. Evidence suggests such education can increase use of home dialysis, reduce catheter use, decrease 90-day mortality, and increase transplantation. While these benefits are encouraging, not all patients are offered options education and when they are, it may not be presented in a way that is immediately applicable to them and their lives. Furthermore, little is known regarding specific characteristics (e.g. format such as group or individual or in-person or online, duration, teaching methods, location, content) of educational programs that are most successful. No single approach has emerged as a best practice. In the absence of such evidence, adult learning principles, such as involving patients and families in the development programs and materials, can serve as a guide for educational development. Adult learning principles can enhance options education, evolving them from information delivery to a person-centered, values-based endeavor that helps match treatment to values and lifestyle.
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Affiliation(s)
| | - L Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Martinez KA, Deshpande A, Ruff AL, Bolen SD, Teng K, Rothberg MB. Are Providers Prepared to Engage Younger Women in Shared Decision-Making for Mammography? J Womens Health (Larchmt) 2018; 27:24-31. [DOI: 10.1089/jwh.2016.6047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
| | | | - Allison L. Ruff
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shari D. Bolen
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Kathryn Teng
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio
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An introduction to Item Response Theory and Rasch Analysis of the Eating Assessment Tool (EAT-10). BRAIN IMPAIR 2017; 19:91-102. [PMID: 29606914 DOI: 10.1017/brimp.2017.31] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Item response theory has its origins in educational measurement and is now commonly applied in health-related measurement of latent traits, such as function and symptoms. This application is due in large part to gains in the precision of measurement attributable to item response theory and corresponding decreases in response burden, study costs, and study duration. The purpose of this paper is twofold: introduce basic concepts of item response theory and demonstrate this analytic approach in a worked example, a Rasch model (1PL) analysis of the Eating Assessment Tool (EAT-10), a commonly used measure for oropharyngeal dysphagia. The results of the analysis were largely concordant with previous studies of the EAT-10 and illustrate for brain impairment clinicians and researchers how IRT analysis can yield greater precision of measurement.
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43
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Newton EH. Addressing overuse in emergency medicine: evidence of a role for greater patient engagement. Clin Exp Emerg Med 2017; 4:189-200. [PMID: 29306268 PMCID: PMC5758625 DOI: 10.15441/ceem.17.233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/05/2017] [Accepted: 06/30/2017] [Indexed: 01/01/2023] Open
Abstract
Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.
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Affiliation(s)
- Erika H. Newton
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
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Sullivan DR, Golden SE, Ganzini L, Wiener RS, Eden KB, Slatore CG. Association of Decision-making with Patients' Perceptions of Care and Knowledge during Longitudinal Pulmonary Nodule Surveillance. Ann Am Thorac Soc 2017; 14:1690-1696. [PMID: 28489453 PMCID: PMC5711278 DOI: 10.1513/annalsats.201612-1021oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/05/2017] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Patient participation in medical decision-making is widely advocated, but outcomes are inconsistent. OBJECTIVES We examined the associations between medical decision-making roles, and patients' perceptions of their care and knowledge while undergoing pulmonary nodule surveillance. METHODS The study setting was an academically affiliated Veterans Affairs hospital network in which 121 participants had 319 decision-making encounters. The Control Preferences Scale was used to assess patients' decision-making roles. Associations between decision-making, including role concordance (i.e., agreement between patients' preferred and actual roles), shared decision-making (SDM), and perceptions of care and knowledge, were assessed using logistic regression and generalized estimating equations. RESULTS Participants had a preferred role in 98% of encounters, and most desired an active role (shared or patient controlled). For some encounters (36%), patients did not report their actual decision-making role, because they did not know what their role was. Role concordance and SDM occurred in 56% and 26% of encounters, respectively. Role concordance was associated with greater satisfaction with medical care (adjusted odds ratio [Adj-OR], 5.39; 95% confidence interval [CI], 1.68-17.26), higher quality of patient-reported care (Adj-OR, 2.86; 95% CI, 1.31-6.27), and more disagreement that care could be better (Adj-OR, 2.16; 95% CI, 1.12-4.16). Role concordance was not associated with improved pulmonary nodule knowledge with respect to lung cancer risk (Adj-OR, 1.12; 95% CI, 0.63-2.00) or nodule information received (Adj-OR, 1.13; 95% CI, 0.31-4.13). SDM was not associated with perceptions of care or knowledge. CONCLUSIONS Among patients undergoing longitudinal nodule surveillance, a majority had a preference for having active roles in decision-making. Interestingly, during some encounters, patients did not know what their role was or that a decision was being made. Role concordance was associated with greater patient-reported satisfaction and quality of medical care, but not with improved knowledge. Patient participation in decision-making may influence perceptions of care; however, clinicians may need to focus on other communication strategies or domains to improve patient knowledge and health outcomes.
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Affiliation(s)
- Donald R. Sullivan
- Health Services Research and Development, and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | | | - Linda Ganzini
- Health Services Research and Development, and
- Division of Geriatric Psychiatry, Department of Psychiatry, and
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts; and
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Karen B. Eden
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Christopher G. Slatore
- Health Services Research and Development, and
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
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Philpott SE, Witteman HO, Jones KM, Sonderman DS, Julien AS, Politi MC. Clinical trainees' responses to parents who question evidence-based recommendations. PATIENT EDUCATION AND COUNSELING 2017; 100:1701-1708. [PMID: 28495389 DOI: 10.1016/j.pec.2017.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/03/2017] [Accepted: 05/01/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We examined clinicians' attitudes, beliefs, and behavioral intentions about discussing evidence and eliciting values when patients question recommendations. METHODS We randomized trainees to read one of three scenarios about a parent of a one-year-old: 1) overuse (parent requests antibiotics for presumed viral infection); 2) equipoise (tubes for recurrent ear infections); 3) underuse (parent hesitates about vaccination). Participants then answered survey questions. Outcomes included time spent clarifying values (primary), attitudes and beliefs about the parent (secondary). RESULTS 132 medical students and pediatric residents enrolled; 119 (90%) completed the study. There were no differences in time participants would spend clarifying values (antibiotics 26±12%; equipoise 28±11%; vaccine-hesitancy 22±11%; p=0.058). Participants in the vaccine-hesitancy group (vs. other groups) would spend less time answering questions (p=0.006). Participants in the antibiotics (vs. equipoise) group perceived the parent as difficult (p=0.0002). Those in the vaccine-hesitancy group (vs. other groups) perceived the parent as difficult, saw less value in the conversation, and had lower respect for the parent's views (all ps<0.0001). Most (76%) wanted additional training navigating these discussions. CONCLUSION Clinicians' attitudes may impact conversations when patients question evidence-based recommendations. PRACTICE IMPLICATIONS Clinicians should consider ways to discuss evidence and clarify patients' values to optimize health without damaging patient-clinician relationships.
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Affiliation(s)
- Sydney E Philpott
- Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Office of Education and Professional Development, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Research Centre, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Katherine M Jones
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - David S Sonderman
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Anne-Sophie Julien
- Research Centre, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Mary C Politi
- Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
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Laviana AA, Pannell SC, Huen KHY, Bergman J. Engaging patients in complex clinical decision-making: Successes, pitfalls, and future directions. Urol Oncol 2017; 35:569-573. [PMID: 28789928 DOI: 10.1016/j.urolonc.2017.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/05/2017] [Accepted: 07/12/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND By 2022, there will be 18 million predicted cancer survivors, which is an estimated 30% more than the number of survivors in 2012. In prostate cancer alone, the most common cancer in American men other than skin cancer, 1 in 7 men will be diagnosed during their lifetime. Nevertheless, only approximately 1 in 39 will actually die of the disease. Although life expectancy is often good, these men have multiple treatment management options to choose from, including active surveillance, surgery, or radiotherapy, each of which carries its own array of long-term adverse effects. The same applies to renal cancer where patient have to sift through information to decide among active surveillance, partial nephrectomy, racial nephrectomy, robotic vs. open surgery, and ablation. BASIC PROCEDURES Ultimately, patient, providers, and stakeholders lack high-quality evidence to effectively guide treatment decisions, and these decisions become even harder to discern when considering end-of-life care, palliative care, and the ethics regarding the new End of Life Option Act. As of November 1, 2016, the number of open urologic cancer clinical trials listed on ClinicalTrials.gov was 843. MAIN FINDINGS Although we continue to make tremendous strides in urologic cancer care, our options for choosing the best treatment from a patient and provider standpoint are seemingly growing murkier. We need to continue to understand how health-related quality of life varies from patient to patient, and ultimately, incorporate patient preferences and values into the treatment decision in order to make high-quality treatment decisions. CONCLUSIONS The remained of this articles will focus on the significant strides made in urologic oncology regarding these difficult decisions from localized disease to end-of-life care and also will detail what needs to be done as we continue to pivot forward.
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Affiliation(s)
- Aaron A Laviana
- Department of Urology, Institute of Urologic Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA.
| | - Stephanie C Pannell
- Department of Urology, Institute of Urologic Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Kathy H Y Huen
- Department of Urology, Institute of Urologic Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Jonathan Bergman
- Department of Family Medicine, David Geffern School of Medicine at UCLA, Los Angeles, CA; Veterans Health Affairs-Greater Los Angeles, Los Angeles, CA; Department of Urology, Olive View-UCLA Medical Center, Sylmar, CA
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Hofmann B. Ethical issues with colorectal cancer screening-a systematic review. J Eval Clin Pract 2017; 23:631-641. [PMID: 28026076 DOI: 10.1111/jep.12690] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 12/26/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening. METHODS An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments. RESULTS A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease. CONCLUSION A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health Science, the Norwegian University for Science and Technology, Gjøvik, Norway.,The Centre of Medical Ethics at the University of Oslo, Norway
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48
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Sepucha KR, Simmons LH, Barry MJ, Edgman-Levitan S, Licurse AM, Chaguturu SK. Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital. Health Aff (Millwood) 2017; 35:630-6. [PMID: 27044963 DOI: 10.1377/hlthaff.2015.1376] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospital's integration of shared decision making into practice has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospital's eighteen adult primary care practices, and we summarize key elements of the shared decision making program.
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Affiliation(s)
- Karen R Sepucha
- Karen R. Sepucha is an assistant professor of medicine at Harvard Medical School and Massachusetts General Hospital (MGH), both in Boston
| | | | - Michael J Barry
- Michael J. Barry is a physician and medical director of the John D. Stoeckle Center for Primary Care Innovation at MGH
| | - Susan Edgman-Levitan
- Susan Edgman-Levitan is executive director of the John D. Stoeckle Center for Primary Care Innovation at MGH
| | - Adam M Licurse
- Adam M. Licurse is assistant medical director of the Brigham and Women's Physicians Organization, a physician at Brigham and Women's Hospital, and associate medical director for population health management at Partners HealthCare, all in Boston
| | - Sreekanth K Chaguturu
- Sreekanth K. Chaguturu is vice president for population health management at Partners HealthCare, a staff physician at MGH, and a clinical instructor at Harvard Medical School
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Le YCL, McFall SL, Byrd TL, Volk RJ, Cantor SB, Kuban DA, Mullen PD. Is "Active Surveillance" an Acceptable Alternative?: A Qualitative Study of Couples' Decision Making about Early-Stage, Localized Prostate Cancer. Narrat Inq Bioeth 2017; 6:51-61. [PMID: 27346824 DOI: 10.1353/nib.2016.0006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The objective of our study was to describe decision making by men and their partners regarding active surveillance (AS) or treatment for early-stage, localized prostate cancer. Fifteen couples were recruited from a cancer center multispecialty clinic, which gave full information about all options, including AS. Data were collected via individual, semi-structured telephone interviews. Most patients were white, non-Hispanic, had private insurance, had completed at least some college, and were aged 49-72 years. Ten chose AS. All partners were female, and couples reported strong marital satisfaction and cohesion. All couples described similar sequences of a highly emotional initial reaction and desire to be rid of the cancer, information seeking, and decision making. The choice of AS was built on a nuanced evaluation of the man's condition in which the couple differentiated prostate cancer from other cancers and early stage from later stages, wanted to avoid/delay side effects, and trusted the AS protocol to identify negative changes in time for successful treatment. Treated couples continued to want immediate treatment to remove the cancer. We concluded that having a partner's support for AS may help a man feel more comfortable with choosing and adhering to AS. Using decision aids that address both a man's and his partner's concerns regarding AS may increase its acceptability. Our research shows that some patients want to and do involve their partners in the decision-making process. Ethical issues are related to the tension between desire for partner involvement and the importance of the patient as autonomous decision-maker. The extended period of decision making, particularly for AS, is also an ethical issue that requires additional support for patients and couples in the making of fully informed choices that includes AS.
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Wolff JL, Guan Y, Boyd CM, Vick J, Amjad H, Roth DL, Gitlin LN, Roter DL. Examining the context and helpfulness of family companion contributions to older adults' primary care visits. PATIENT EDUCATION AND COUNSELING 2017; 100:487-494. [PMID: 27817986 PMCID: PMC5350029 DOI: 10.1016/j.pec.2016.10.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/14/2016] [Accepted: 10/22/2016] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Older adults commonly involve family (broadly defined) in their care. We examined communication behaviors of family companions during older adults' primary care visits, including whether these behaviors vary with respect to how older adults manage their health, preferences for involving family in medical decision-making, and ratings of companion helpfulness. METHODS Analysis of audio-taped primary care visits of older patients who were accompanied by a family companion (n=30 dyads) and linked patient surveys. RESULTS Family companions predominantly facilitated doctor and patient information exchange. More than half of companion communication behaviors were directed at improving doctor understanding of the patient. Companions were more verbally active during visits of patients who delegated the management of their health to others than visits of patients who co-managed or self-managed their health. Companions were rated as more helpful by patients who preferred active involvement of family in medical decision-making. CONCLUSION Family companion participation and helpfulness in primary care communication varies by patients' preferences for involving family in medical decision-making and approach to manage their health. PRACTICE IMPLICATIONS Research to examine the effects of clarifying patient and family companion expectations for primary care visits could inform strategies to improve the patient-centeredness of medical communication.
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Affiliation(s)
- Jennifer L Wolff
- Department of Health Policy and Management and Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 692, Baltimore, MD 21205, United States; Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD 21224-2734, United States; Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-700, Baltimore, MD 21205-2223, United States; Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Suite 316, Baltimore, MD 21205-2110, United States.
| | - Yue Guan
- Program in Personalized & Genomic Medicine, Division of Endocrinology, Diabetes & Nutrition, Department of Medicine, University of Maryland School of Medicine, 685 W. Baltimore St., MSTF 3-14D, Baltimore, MD 21201, United States.
| | - Cynthia M Boyd
- Department of Health Policy and Management and Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 692, Baltimore, MD 21205, United States; Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD 21224-2734, United States; Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-700, Baltimore, MD 21205-2223, United States; Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Suite 316, Baltimore, MD 21205-2110, United States.
| | - Judith Vick
- Johns Hopkins University School of Medicine, Edward D. Miller Research Building, 733 North Broadway, Suite 137, Baltimore, MD 21205-2196, United States
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD 21224-2734, United States; Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-700, Baltimore, MD 21205-2223, United States; Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Suite 316, Baltimore, MD 21205-2110, United States.
| | - David L Roth
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD 21224-2734, United States; Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-700, Baltimore, MD 21205-2223, United States; Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Suite 316, Baltimore, MD 21205-2110, United States.
| | - Laura N Gitlin
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD 21224-2734, United States; Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-700, Baltimore, MD 21205-2223, United States; Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Suite 316, Baltimore, MD 21205-2110, United States.
| | - Debra L Roter
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 750, Baltimore, MD 21205205, United States.
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