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Friedrich NA, Luu M, Gale R, Chaplin A, Ballas L, Sandler HM, Posadas EM, Freedland SJ, Spiegel B, Kokorowski P, Daskivich TJ. Variation in content discussed by specialty in consultations for clinically localized prostate cancer. Urol Oncol 2024; 42:288.e7-288.e15. [PMID: 38762384 PMCID: PMC11193607 DOI: 10.1016/j.urolonc.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/31/2024] [Accepted: 04/11/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Multidisciplinary consultations improve decisional conflict and guideline-concordant treatment for men with prostate cancer (PC), but differences in the content discussed by specialty during consultations are unknown. METHODS We audiorecorded and transcribed 50 treatment consultations for localized PC across a multidisciplinary sample of urologists, radiation oncologists, and medical oncologists. Conversation was coded for narrative content using an open coding approach, grouping similar topics into major content areas. The number of words devoted to each content area per consult was used as a proxy for time spent. Multivariable Poisson regression calculated incidence rate ratios (IRR) for content-specific word count across specialties after adjustment for tumor risk and patient demographics. RESULTS Coders identified 8 narrative content areas: overview of PC; medical history; baseline risk; cancer prognosis; competing risks; treatment options; physician recommendations; and shared decision making (SDM). In multivariable models, specialties significantly differed in proportion of time spent on treatment options, SDM, competing risks, and cancer prognosis. Urologists spent 1.8-fold more time discussing cancer prognosis than medical oncologists (IRR1.80, 95%CI:1.14-2.83) and radiation oncologists (IRR1.84, 95%CI:1.10-3.07). Urologists (IRR11.38, 95%CI:6.62-19.56) and medical oncologists (IRR10.60, 95%CI:6.01-18.72) spent over 10-fold more time discussing competing risks than radiation oncologists. Medical oncologists (IRR2.60, 95%CI:1.65-4.10) and radiation oncologists (IRR1.77, 95%CI:1.06-2.95) spent 2.6- and 1.8-fold more time on SDM than urologists, respectively. CONCLUSIONS Specialists focus on different content in PC consultations. Our results suggest that urologists should spend more time on SDM and radiation oncologists on competing risks. Our results also highlight the importance of medical oncologists in facilitating SDM.
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Affiliation(s)
- Nadine A Friedrich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Biostatistics and Bioinformatics Core, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes. Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Antwon Chaplin
- Cedars-Sinai Center for Outcomes. Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Leslie Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edwin M Posadas
- Department of Medicine, Division of Hematology and Oncology, Cedars-Sinai Medical Center, Los Angeles , CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Surgery, Urology Section, Veterans Affairs Health Care System, Durham, NC, USA; Center for Integrated Research in Cancer and Lifestyle, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes. Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Pediatrics,Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Paul Kokorowski
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Pediatrics,Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes. Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Wieringa TH, León-García M, Espinoza Suárez NR, Hernández-Leal MJ, Jacome CS, Zisman-Ilani Y, Otten RHJ, Montori VM, Pieterse AH. The role of time in involving patients with cancer in treatment decision making: A scoping review. PATIENT EDUCATION AND COUNSELING 2024; 125:108285. [PMID: 38701622 DOI: 10.1016/j.pec.2024.108285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Time is often perceived as a barrier to shared decision making in cancer care. It remains unclear how time functions as a barrier and how it could be most effectively utilized. OBJECTIVE This scoping review aimed to describe the role of time in patient involvement, and identify strategies to overcome time-related barriers. METHODS Seven databases were searched for any publications on patient involvement in cancer treatment decisions, focusing on how time is used to involve patients, the association between time and patient involvement, and/or strategies to overcome time-related barriers. Reviewers worked independently and in duplicate to select publications and extract data. One coder thematically analyzed data, a second coder checked these analyses. RESULTS The analysis of 26 eligible publications revealed four themes. Time was a resource 1) to process the diagnosis, 2) to obtain/process/consider information, 3) for patients and clinicians to spend together, and 4) for patient involvement in making decisions. DISCUSSION Time is a resource throughout the treatment decision-making process, and generic strategies have been proposed to overcome time constraints. PRACTICE VALUE Clinicians could co-create decision-making timelines with patients, spread decisions across several consultations, share written information with patients, and support healthcare redesigns that allocate the necessary time.
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Affiliation(s)
- Thomas H Wieringa
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands; Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Montserrat León-García
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Department of Pediatrics, Obstetrics, Gynecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Nataly R Espinoza Suárez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Center for Sustainable Health Research, Integrated University Health and Social Services Center of Capitale-Nationale, Quebec City, QC, Canada; Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | - María José Hernández-Leal
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Department of Economics, Rovira i Virgili University, Tarragona, Spain; University of Navarra, School of Nursing, Department of Community, Maternity and Pediatric Nursing, Campus Universitario, 31008 Pamplona, Spain; Millennium Nucleus on Sociomedicine, 750908 Santiago, Chile
| | - Cristian Soto Jacome
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Division of Internal Medicine, Department of Medicine, Norwalk Hospital, Norwalk, CT, USA
| | - Yaara Zisman-Ilani
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA; Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, University College London, London, UK
| | - René H J Otten
- Walaeus Library, Leiden University Medical Center, Leiden, the Netherlands
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands.
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Verdugo J, Laughter L, Chambers DW. Shared decision-making in scaling and root planing. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2024; 28:184-190. [PMID: 37571971 DOI: 10.1111/eje.12935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/22/2023] [Accepted: 07/08/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION Estimate proportion of various approaches used by dental hygienists for engaging patients in decisions commonly arising during scaling and root planing. Distribution of approaches was compared across various task components in this procedure, practice experience of dental hygienists and patient compliance. MATERIALS AND METHODS Survey of graduates from and students in a baccalaureate dental hygiene program. RESULTS Paternalism (tell then do) and informed consent (give choices and reasons and ask for permission) were more common than shared decision-making (discuss alternatives, solicit patient input and arrive at a mutual decision) and disengagement (patient refusing offered service or avoiding further involvement) by a ratio of 4 to 1 for the first 2 compared with the latter 2. This relationship was held across selecting treatment, procedural adjuncts, homecare instructions and financial arrangements. Dental hygienists exhibited a range of personal preferences for engagement approaches. No-show rate, patient disengagement outside the office, was high (20%). CONCLUSION Dental hygienists reported using 'more controlled' approaches to engaging patients in decisions regarding treatment. Patients may prefer to engage in more shared decisions and choose this approach by staying away from the office. This may underestimate patients' decisions to stay away from treatment, for example by not showing for completion of the treatment or disregarding homecare routines.
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Affiliation(s)
- José Verdugo
- The University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California, USA
| | - Lory Laughter
- The University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California, USA
| | - David W Chambers
- The University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California, USA
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Ippolito GM, Reines K, Meeks WD, Mbassa R, Ellimoottil C, Faris A, Reuland DS, Nielsen ME, Teal R, Vu M, Clemens JQ, Tan HJ. Perceived vs Actual Shared Decision-Making Behavior Among Urologists: A Convergent, Parallel, Mixed-Methods Study of Self-Reported Practice. Urology 2024; 183:78-84. [PMID: 37996015 DOI: 10.1016/j.urology.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/30/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To evaluate the association between self-perceived use of shared decision-making among urologists with use of validated prediction tools and self-described surgical decision-making. METHODS This is a convergent mixed methods study of these parallel data from two modules (Shared Decision Making and Validated Prediction tools) within the 2019 American Urological Association (AUA) Annual Census. The shared decision-making (SDM) module queried aspects of SDM that urologists regularly used. The validated prediction tools module queried whether urologists regularly used, trusted, and found prediction tools helpful. Selected respondents to the 2019 AUA Annual Census underwent qualitative interviews on their surgical decision-making. RESULTS In the weight sampled of 12,312 practicing urologists, most (77%) reported routine use of SDM, whereas only 30% noted regular use of validated prediction tools. On multivariable analysis, users of prediction tools were not associated with regular SDM use (31% vs 28%, P = .006) though was associated with use of decision aids f (32% vs 26%, P < .001). Shared decision-making emerged thematically with respect to matching treatment options, prioritizing goals, and navigating challenging decisions. However, the six specific components of shared decision-making ranged in their mentions within qualitative interviews. CONCLUSION Most urologists report performing SDM as supported by its thematic presence in surgical decision-making. However, only a minority use validated prediction tools and urologists infrequently mention specific SDM components. This discrepancy provides an opportunity to explore how urologists perform SDM and can be used to support integrated strategies to implement SDM more effectively in clinical practice.
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Affiliation(s)
- Giulia M Ippolito
- Department of Urology, University of Michigan, Ann Arbor, MI; Ann Arbor VA Medical Center, Ann Arbor, MI.
| | - Katy Reines
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - William D Meeks
- American Urological Association (AUA), Data Management and Statistical Analysis, Linthicum, MD; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Rachel Mbassa
- American Urological Association (AUA), Data Management and Statistical Analysis, Linthicum, MD; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Anna Faris
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Daniel S Reuland
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Maihan Vu
- Lineberger Comprehensive Cancer Center, Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
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Hu S, Chang CP, Snyder J, Deshmukh V, Newman M, Date A, Galvao C, Porucznik CA, Gren LH, Sanchez A, Lloyd S, Haaland B, O'Neil B, Hashibe M. Comparing Active Surveillance and Watchful Waiting With Radical Treatment Using Machine Learning Models Among Patients With Prostate Cancer. JCO Clin Cancer Inform 2023; 7:e2300083. [PMID: 37988640 PMCID: PMC10681553 DOI: 10.1200/cci.23.00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/20/2023] [Accepted: 09/13/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE In 2021, 59.6% of low-risk patients with prostate cancer were under active surveillance (AS) as their first course of treatment. However, few studies have investigated AS and watchful waiting (WW) separately. The objectives of this study were to develop and validate a population-level machine learning model for distinguishing AS and WW in the conservative treatment group, and to investigate initial cancer management trends from 2004 to 2017 and the risk of chronic diseases among patients with prostate cancer with different treatment modalities. METHODS In a cohort of 18,134 patients with prostate adenocarcinoma diagnosed between 2004 and 2017, 1,926 patients with available AS/WW information were analyzed using machine learning algorithms with 10-fold cross-validation. Models were evaluated using performance metrics and Brier score. Cox proportional hazard models were used to estimate hazard ratios for chronic disease risk. RESULTS Logistic regression models achieved a test area under the receiver operating curve of 0.73, F-score of 0.79, accuracy of 0.71, and Brier score of 0.29, demonstrating good calibration, precision, and recall values. We noted a sharp increase in AS use between 2004 and 2016 among patients with low-risk prostate cancer and a moderate increase among intermediate-risk patients between 2008 and 2017. Compared with the AS group, radical treatment was associated with a lower risk of prostate cancer-specific mortality but higher risks of Alzheimer disease, anemia, glaucoma, hyperlipidemia, and hypertension. CONCLUSION A machine learning approach accurately distinguished AS and WW groups in conservative treatment in this decision analytical model study. Our results provide insight into the necessity to separate AS and WW in population-based studies.
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Affiliation(s)
- Siqi Hu
- Huntsman Cancer Institute, Salt Lake City, UT
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Chun-Pin Chang
- Huntsman Cancer Institute, Salt Lake City, UT
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - John Snyder
- Intermountain Healthcare, Salt Lake City, UT
| | | | - Michael Newman
- University of Utah Health Sciences Center, Salt Lake City, UT
| | - Ankita Date
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT
| | - Carlos Galvao
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT
| | - Christina A. Porucznik
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Lisa H. Gren
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Alejandro Sanchez
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah School of Medicine, Salt Lake City, UT
| | - Benjamin Haaland
- Huntsman Cancer Institute, Salt Lake City, UT
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Brock O'Neil
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Mia Hashibe
- Huntsman Cancer Institute, Salt Lake City, UT
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Rencsok EM, Stopsack KH, Slopen N, Odedina FT, Ragin C, Nowak J, McSwain L, Manarite J, Heath E, George DJ, Kantoff PW, Vinson J, Villanti P, Haneuse S, Mucci LA. Experience with the US health care system for Black and White patients with advanced prostate cancer. Cancer 2023; 129:2532-2541. [PMID: 37246339 PMCID: PMC10524970 DOI: 10.1002/cncr.34885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The purpose of this study was to assess differences in reported information about treatment, integration into care, and respect by self-identified Black and White individuals with advanced prostate cancer in the United States. PATIENTS AND METHODS This is a prospective cohort study of 701 participants (20% identifying as Black) enrolled in the International Registry for Men with Advanced Prostate Cancer at 37 US sites from 2017 to 2022. Participants were asked six questions from the Cancer Australia National Cancer Control Indicators about their experience with care at study enrollment. Prevalence differences by self-reported race were estimated using marginal standardization of logistic-normal mixed effects models (adjusted for age at enrollment and disease state at enrollment), and 95% CIs were estimated using parametric bootstrapping. RESULTS Most participants reported a high quality of care for each question. Black participants generally reported higher care quality compared with White participants. Black participants reported more frequently that they were offered a written assessment and care plan (71%) compared with White participants (58%; adjusted difference, 13 percentage points; 95% CI, 4-23). Black participants also reported more frequently being given the name of nonphysician personnel who would support them (64%) than White participants (52%; adjusted difference, 10; 95% CI, 1-20). Prevalence differences did not differ by disease state at enrollment. CONCLUSIONS Black participants generally reported a higher quality of care compared with White participants. This study calls attention to the need to study potential mediating factors and interpersonal aspects of care in this population to improve survivorship.
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Affiliation(s)
- Emily M Rencsok
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Harvard-MIT Division of Health Sciences and Technology, Harvard Medical School, Boston, Massachusetts, USA
| | - Konrad H Stopsack
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Natalie Slopen
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Folakemi T Odedina
- Mayo Clinic Comprehensive Cancer Center, Jacksonville, Florida, USA
- Prostate Cancer Transatlantic Consortium (CaPTC), Jacksonville, Florida, USA
| | - Camille Ragin
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
- African-Caribbean Cancer Consortium, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | - Philip W Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Convergent Therapeutics, Cambridge, Massachusetts, USA
| | - Jacob Vinson
- Prostate Cancer Clinical Trials Consortium (PCCTC), New York, New York, USA
| | | | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Lorelei A Mucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Jamy OH, Dudley WN, Dudley LS, Scott JM, Wujcik D. Goals, preferences, and concerns of patients with acute myeloid leukemia at time of treatment decision. J Geriatr Oncol 2023; 14:101555. [PMID: 37327759 DOI: 10.1016/j.jgo.2023.101555] [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: 12/07/2022] [Revised: 05/16/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Current cancer value-based models require documentation of patient goals of care and an evidence-based treatment course commensurate with patient goals. This feasibility study assessed the utility of an electronic tablet-based questionnaire to elicit patient goals, preferences, and concerns at a treatment decision making time point in patients with acute myeloid leukemia. MATERIALS AND METHODS Seventy-seven patients were recruited from three institutions prior to seeing the physician for treatment decision-making visit. Questionnaires included demographics, patient beliefs, and decision-making preferences. Analyses included standard descriptive statistics appropriate for the level of measurement. RESULTS Median age was 71 (range = 61-88), 64.9% female, 87.0% white, and 48.6% college educated. On average, patients completed the surveys unassisted in 16.24 min and providers reviewed the dashboard in 3.5 min. All but one patient completed the survey prior to starting treatment (98.7%). Providers reviewed the survey results prior to seeing the patient 97.4% of the time. When asked their goals of care, 57 (74.0%) patients agreed with the statement "my cancer is curable" and 75 (97.4%) agreed that the treatment goal was to get rid of all cancer. Seventy-seven (100%) agreed the goal of care is to feel better and 76 (98.7%) agreed the goal of care is live longer. Forty-one (53.9%) indicated they wanted to make treatment decisions together with the provider. The top two concerns were understanding treatment options (n = 24; 31.2%) and making the right decision (n = 22; 28.6%). DISCUSSION This pilot demonstrated the feasibility of using technology for decision-making at the point of care. Eliciting patient goals of care, treatment outcomes expectations, decision-making preferences, and top concerns may provide clinicians with information to inform the treatment discussion. A simple electronic tool may provide valuable insight into patient understanding of disease to better tailor patient-provider discussion and treatment decision-making.
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Affiliation(s)
- Omer Hassan Jamy
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - William N Dudley
- Piedmont Research Strategies, Inc, Greensboro, NC, United States of America.
| | - Leah S Dudley
- Piedmont Research Strategies, Inc, Greensboro, NC, United States of America
| | - Julie M Scott
- Carevive Systems, Inc, Miami, FL, United States of America.
| | - Debra Wujcik
- Carevive Systems, Inc, Miami, FL, United States of America.
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Buckley MT, O'Shea MR, Kundu S, Lipitz-Snyderman A, Kuperman G, Shah S, Iasonos A, Houston C, Terzulli SL, Lengfellner JM, Sabbatini P. Digitalizing the Clinical Research Informed Consent Process: Assessing the Participant Experience in Comparison With Traditional Paper-Based Methods. JCO Oncol Pract 2023; 19:e355-e364. [PMID: 36534933 PMCID: PMC10022878 DOI: 10.1200/op.22.00425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/14/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Consent processes are critical for clinical care and research and may benefit from incorporating digital strategies. We compared an electronic informed consent (eIC) option to paper consent across four outcomes: (1) technology burden, (2) protocol comprehension, (3) participant agency (ability to self-advocate), and (4) completion of required document fields. METHODS We assessed participant experience with eIC processes compared with traditional paper-based consenting using surveys and compared completeness of required fields, over 3 years (2019-2021). Participants who consented to a clinical trial at a large academic cancer center via paper or eIC were invited to either pre-COVID-19 pandemic survey 1 (technology burden) or intrapandemic survey 2 (comprehension and agency). Consent document completeness was assessed via electronic health records. RESULTS On survey 1, 83% of participants (n = 777) indicated eIC was easy or very easy to use; discomfort with technology overall was not correlated with discomfort using eIC. For survey 2, eIC (n = 262) and paper consenters (n = 193) had similar comprehension scores. All participants responded favorably to at least five of six agency statements; however, eIC generated a higher proportion of positive free-text comments (P < .05), with themes such as thoroughness of the discussion and consenter professionalism. eIC use yielded no completeness errors across 235 consents versus 6.4% for paper (P < .001). CONCLUSION Our findings suggest that eIC when compared with paper (1) did not increase technology burden, (2) supported comparable comprehension, (3) upheld key elements of participant agency, and (4) increased completion of mandatory consent fields. The results support a broader call for organizations to offer eIC for clinical research discussions to enhance the overall participant experience and increase the completeness of the consent process.
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Affiliation(s)
| | | | | | | | | | - Suken Shah
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Paul Sabbatini
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
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9
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Veenendaal HV, Chernova G, Bouman CM, Etten-Jamaludin FSV, Dieren SV, Ubbink DT. Shared decision-making and the duration of medical consultations: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2023; 107:107561. [PMID: 36434862 DOI: 10.1016/j.pec.2022.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/07/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE 1) determine whether increased levels of Shared Decision-Making (SDM) affect consultation duration, 2) investigate the intervention characteristics involved. METHODS MEDLINE, EMBASE, CINAHL and Cochrane library were systematically searched for experimental and cross-sectional studies up to December 2021. A best-evidence synthesis was performed, and interventions characteristics that increased at least one SDM-outcome, were pooled and descriptively analyzed. RESULTS Sixty-three studies were selected: 28 randomized clinical trials, 8 quasi-experimental studies, and 27 cross-sectional studies. Overall, pooling of data was not possible due to substantial heterogeneity. No differences in consultation duration were found more often than increased or decreased durations. . Consultation times (minutes:seconds) were significantly increased only among interventions that: 1) targeted clinicians only (Mean Difference [MD] 1:30, 95% Confidence Interval [CI] 0:24-2:37); 2) were performed in primary care (MD 2:05, 95%CI 0:11-3:59; 3) used a group format (MD 2:25, 95%CI 0:45-4:05); 4) were not theory-based (MD 4:01, 95%CI 0:38-7:23). CONCLUSION Applying SDM does not necessarily require longer consultation durations. Theory-based, multilevel implementation approaches possibly lower the risk of increasing consultation durations. PRACTICE IMPLICATIONS The commonly heard concern that time hinders SDM implementation can be contradicted, but implementation demands multifaceted approaches and space for training and adapting work processes.
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Affiliation(s)
- Haske van Veenendaal
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, the Netherlands.
| | - Genya Chernova
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Carlijn Mb Bouman
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Faridi S van Etten-Jamaludin
- Amsterdam UMC, location University of Amsterdam, Medical Library AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands.
| | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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10
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Martinez KA, Linfield DT, Shaker V, Rothberg MB. Informed Decision Making for Anticoagulation Therapy for Atrial Fibrillation. Med Decis Making 2023; 43:263-269. [PMID: 36059267 PMCID: PMC9825626 DOI: 10.1177/0272989x221121350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) must decide between warfarin and direct oral anticoagulants (DOACs), a decision involving important tradeoffs. Our objective was to understand whether physicians engage patients in informed decision making for anticoagulants. DESIGN We performed an analysis of recorded conversations between physicians and anticoagulation-naïve patients in the Verilogue Point-of-Practice database. We assessed the presence of 7 elements of informed decision making, as well as a discussion of financial costs. RESULTS Of 37 encounters with 21 physicians, 92% resulted in a DOAC prescription and 8% resulted in a warfarin prescription. Seventy percent met criteria for discussion of pros and cons, 70% for discussion of the alternatives, 43% presented the decision, 30% included an assessment of patient understanding, 22% included an explanation of the patient's role in decision making, 22% included an assessment of patient preferences, and 19% included a discussion of uncertainty. Two encounters (5%) included all 7 elements and 9 (24%) included none. Physicians discussed treatment costs with patients in 43% of encounters. LIMITATIONS We assessed informed decision making in a single encounter. Physicians and patients may have had other discussions that were not captured in our data. CONCLUSIONS Physicians often presented the alternatives but did not generally engage patients in informed decision making. The high rate of DOAC prescriptions is likely the result of physician preferences, as patient preferences were rarely assessed. IMPLICATIONS Strategies to support physicians in engaging patients in informed decision making for anticoagulation are needed. HIGHLIGHTS While physicians discussed the alternatives and presented pros and cons with patients, they rarely assessed patient preferences, explained the patient's role in decision making, or addressed uncertainty.The cost of treatment with DOACs versus warfarin was discussed by physicians in less than half of encounters, limiting patients' ability to make informed decisions for anticoagulation.Only 2 encounters (5%) fulfilled all 7 elements of informed decision making.
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11
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Rake EA, Box ICH, Dreesens D, Meinders MJ, Kremer JAM, Aarts JWM, Elwyn G. Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:2860-2870. [PMID: 35659466 DOI: 10.1016/j.pec.2022.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Proponents of shared decision-making (SDM) advocate the elicitation of the patient's perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient's personal preferences, values and/or context. METHODS A search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument). RESULTS The search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed. CONCLUSIONS PPE occurs on a very low level in efforts to achieve SDM according to evaluation studies. PRACTICE IMPLICATIONS PPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.
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Affiliation(s)
- Ester A Rake
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands; Knowledge Institute of Medical Specialists, Utrecht, The Netherlands.
| | - Ivana C H Box
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Dunja Dreesens
- Knowledge Institute of Medical Specialists, Utrecht, The Netherlands.
| | - Marjan J Meinders
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Jan A M Kremer
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Johanna W M Aarts
- Department of Gynaecological oncology, Amsterdam UMC University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Glyn Elwyn
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.
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12
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Holmboe ES, Kogan JR. Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1128-1136. [PMID: 35294414 PMCID: PMC9311475 DOI: 10.1097/acm.0000000000004667] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Undergraduate and graduate medical education have long embraced uniqueness and variability in curricular and assessment approaches. Some of this variability is justified (warranted or necessary variation), but a substantial portion represents unwarranted variation. A primary tenet of outcomes-based medical education is ensuring that all learners acquire essential competencies to be publicly accountable to meet societal needs. Unwarranted variation in curricular and assessment practices contributes to suboptimal and variable educational outcomes and, by extension, risks graduates delivering suboptimal health care quality. Medical education can use lessons from the decades of study on unwarranted variation in health care as part of efforts to continuously improve the quality of training programs. To accomplish this, medical educators will first need to recognize the difference between warranted and unwarranted variation in both clinical care and educational practices. Addressing unwarranted variation will require cooperation and collaboration between multiple levels of the health care and educational systems using a quality improvement mindset. These efforts at improvement should acknowledge that some aspects of variability are not scientifically informed and do not support desired outcomes or societal needs. This perspective examines the correlates of unwarranted variation of clinical care in medical education and the need to address the interdependency of unwarranted variation occurring between clinical and educational practices. The authors explore the challenges of variation across multiple levels: community, institution, program, and individual faculty members. The article concludes with recommendations to improve medical education by embracing the principles of continuous quality improvement to reduce the harmful effect of unwarranted variation.
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Affiliation(s)
- Eric S. Holmboe
- E.S. Holmboe is chief, research, milestones development, and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-0108-6021
| | - Jennifer R. Kogan
- J.R. Kogan is associate dean, Student Success and Professional Development, and professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0001-8426-9506
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13
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Driggers KE, Dishman SE, Chung KK, Olsen CH, Ryan AB, McLawhorn MM, Johnson LS. Perceptions of care following initiation of do-not-resuscitate orders. J Crit Care 2022; 69:154008. [DOI: 10.1016/j.jcrc.2022.154008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
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14
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Al Qadire M, Al Omari O, Alharrasi M, Al Sabei S, Aljezawi M, Khalaf A. Public information needs and attitudes regarding cancer and cancer patients in Oman: a cross-sectional survey. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S34-S40. [PMID: 35648668 DOI: 10.12968/bjon.2022.31.10.s34] [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] [Indexed: 06/15/2023]
Abstract
BACKGROUND Exploring public information needs and attitudes towards cancer patients might be the first step in developing an intervention that encourages public engagement in early detection and cancer prevention programmes. AIM To explore Omani public information needs and attitudes towards cancer in Oman. METHODS A cross-sectional survey design was used. FINDINGS Of the 569 participants, 369 (64.9%) were female; the mean age was 30.9 (SD=9.5) years. Of the participants, 94.4% wanted to be informed if they were found to have cancer in the future. The mean total attitudes score was 40.2 (SD=4.7) out of a maximum 48. Further, being employed, preferring to be informed about cancer diagnosis and having positive attitudes towards cancer and cancer patients predicted higher information needs. CONCLUSIONS The current paternalistic approach seems to be no longer appropriate for cancer patients in Oman, and more active patient involvement in decision-making is needed.
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Affiliation(s)
- Mohammad Al Qadire
- Associate Professor, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman, and Professor, Adult Health Department, Faculty of Nursing, Al Al-Bayt University, Jordan
| | - Omar Al Omari
- Associate Professor, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Maryam Alharrasi
- Associate Professor, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Sulaiman Al Sabei
- Associate Professor, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Ma'en Aljezawi
- Associate Professor, Community Health Department, Faculty of Nursing, Al Al-Bayt University, Jordan
| | - Atika Khalaf
- Associate Professor, Faculty of Health Sciences, Kristianstad University, Sweden; and Assistant Professor, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
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15
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Informed Decision-Making as a Patient-Centered Initiative in Surgical Planning: In Reply to Fink and Colleagues. J Am Coll Surg 2022; 234:976-977. [DOI: 10.1097/xcs.0000000000000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Gillman AS, Ferrer RA. Opportunities for theory-informed decision science in cancer control. Transl Behav Med 2021; 11:2055-2064. [PMID: 34850928 DOI: 10.1093/tbm/ibab141] [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: 12/11/2022] Open
Abstract
Cancer prevention and control involves navigation of complex clinical decisions, often laden with uncertainty and/or intricate interpersonal dynamics, which have implications for both physical health and quality of life. Cancer decision-making research in recent decades has primarily focused on working to improve the quality of decisions by providing patients with detailed information about their choices and through an increased emphasis in medicine on the importance of shared decision making. This emphasis is reflective of a model of decision making that emphasizes knowledge, options, and deliberative synthesis of information as primary to decision making; yet, decades of research in psychology, decision science, and behavioral economics have taught us that our decisions are not influenced only by our objective knowledge of facts, but by our emotions, by the influence of others, and by biased cognitive processes. We present a conceptual framework for a future of research in decision science and cancer that is informed by decision science theories. Our framework incorporates greater recognition of the interpersonal dynamics of shared decision making, including the biases (including cognitive heuristics and race-based bias) that may affect multiple actors in the decision-making process, and emphasizes study of the interaction between deliberative and affective psychological processes as they relate to decision making. This work should be conducted with an eye toward informing efforts to improve decision making across the cancer care continuum, through interventions that are also informed by theory.
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Affiliation(s)
- Arielle S Gillman
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-9761, USA
| | - Rebecca A Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-9761, USA
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17
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Patients' perspective on shared decision-making in urology: a prospective study at a university hospital. World J Urol 2021; 39:4491-4498. [PMID: 34338818 DOI: 10.1007/s00345-021-03794-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE This study aims to determine the degree of shared decision-making (SDM) from urological patients' perspective and to identify possible predictors. METHODS Overall, 469 urological patients of a university outpatient clinic were recruited for this prospective study. Before a medical consultation, clinical and sociodemographic information, and patients' emotional distress were assessed by questionnaires. After the consultation, patients completed the SDM-Questionnaire-9 (SDM-Q-9). The SDM-Q-9 scores of relevant subgroups were compared. Logistic regression was used to identify patients at risk for experiencing low involvement (SDM-Q-9 total score ≤ 66) in SDM. RESULTS Data from 372 patients were available for statistical analyses. The SDM-Q-9 mean total score was 77.8 ± 20.6. The majority of patients (n = 271, 73%) experienced a high degree of involvement (SDM-Q-9 total score > 66). The mean score per SDM-Q-9 item was in the upper range (3.9 ± 1.4 out of 5). The most poorly rated item was "My doctor wanted to know how I want to be involved in decision-making" (3.5 ± 1.6). Immigration status (OR 3.7, p = 0.049), and nonscheduled hospital registration (OR 2.1, p = 0.047) were significant predictors for less perceived involvement. Comorbidity, oncological status, and emotional distress did not significantly predict perceived participation. CONCLUSION In a university hospital setting, most urological patients feel adequately involved in SDM. Nevertheless, urologists should routinely ask for patients' participation preference. Patients without a scheduled appointment and patients who immigrated may need more support to feel involved in SDM.
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18
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Gillman AS, Vo JB, Nohria A, Ferrer RA. Decision Science Can Inform Clinical Trade-Offs Regarding Cardiotoxic Cancer Treatments. JNCI Cancer Spectr 2021; 5:pkab053. [PMID: 34350379 PMCID: PMC8328021 DOI: 10.1093/jncics/pkab053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/19/2021] [Accepted: 04/30/2021] [Indexed: 12/22/2022] Open
Abstract
Cancer treatment-related cardiotoxicity (ie, heart failure, coronary artery disease, vascular diseases, arrhythmia) is a growing cancer survivorship concern within oncology practice; heart disease is the leading cause of noncancer death in cancer survivors and surpasses cancer as the leading cause of death for some cancers with higher survival rates. The issue of cardiotoxicity introduces a critical tradeoff that must be acknowledged and reconciled in clinical oncology practice: treating cancer aggressively and effectively in the present vs preventing future cardiotoxicity. Although many cancers must be treated as aggressively as possible, for others, multiple treatment options are available. Yet even when effective and less cardiotoxic treatments are available, they are not always chosen. Wariness to choose equally effective but less cardiotoxic treatment options may result in part from providers' and patients' reliance on "cognitive heuristics," or mental shortcuts that people (including, research shows, medical professionals) use to simplify complex judgments. These heuristics include delay discounting, availability and affect heuristics, and default bias. In the current commentary, we describe relevant research that illuminates how use of heuristics leads to biased medical decision making and translate how this research may apply when the tradeoff between aggressive cancer treatment and preventing future cardiotoxicity is considered. We discuss the implications of these biases in oncology practice, offer potential solutions to reduce bias, and call for future research in this area.
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Affiliation(s)
- Arielle S Gillman
- Division of Cancer Control and Population Sciences, Cancer Prevention Fellowship Program, Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Jacqueline B Vo
- Division of Cancer Epidemiology and Genetics, Cancer Prevention Fellowship Program, Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Anju Nohria
- Cardio-Oncology Program, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA, USA
| | - Rebecca A Ferrer
- Division of Cancer Control and Population Sciences, Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute, Bethesda, MD, USA
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19
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Ellis SD, Hwang S, Morrow E, Kimminau KS, Goonan K, Petty L, Ellerbeck E, Thrasher JB. Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists. BMC Cancer 2021; 21:649. [PMID: 34058998 PMCID: PMC8165996 DOI: 10.1186/s12885-021-08386-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting. METHODS We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention. RESULTS Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation. CONCLUSIONS Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.
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Affiliation(s)
- Shellie D. Ellis
- Department of Population Health, School of Medicine, University of Kansas, Kansas City, KS USA
| | - Soohyun Hwang
- Department of Health Policy and Management, School of Public Health, University of North Carolina Chapel Hill, 135 Dauer Drive, 1101 McGavran-Greenberg Hall, Chapel Hill, NC 27599-7411 USA
| | - Emily Morrow
- Department of Sociology, University of Kansas, Kansas City, KS USA
| | - Kim S. Kimminau
- Department of Family Medicine, School of Medicine, University of Kansas, Kansas City, KS USA
| | - Kelly Goonan
- Independent Researcher/Consultant/Scientific Writer, Greensboro, NC USA
| | - Laurie Petty
- Department of Sociology, University of Kansas, Kansas City, KS USA
| | - Edward Ellerbeck
- Department of Population Health, School of Medicine, University of Kansas, Kansas City, KS USA
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20
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Fagerlin A, Holmes-Rovner M, Hofer TP, Rovner D, Alexander SC, Knight SJ, Ling BS, A Tulsky J, Wei JT, Hafez K, Kahn VC, Connochie D, Gingrich J, Ubel PA. Head to head randomized trial of two decision aids for prostate cancer. BMC Med Inform Decis Mak 2021; 21:154. [PMID: 33980208 PMCID: PMC8117645 DOI: 10.1186/s12911-021-01505-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background While many studies have tested the impact of a decision aid (DA) compared to not receiving any DA, far fewer have tested how different types of DAs affect key outcomes such as treatment choice, patient–provider communication, or decision process/satisfaction. This study tested the impact of a complex medical oriented DA compared to a more simplistic decision aid designed to encourage shared decision making in men with clinically localized prostate cancer.
Methods 1028 men at 4 VA hospitals were recruited after a scheduled prostate biopsy. Participants completed baseline measures and were randomized to receive either a simple or complex DA. Participants were men with clinically localized cancer (N = 285) by biopsy and who completed a baseline survey. Survey measures: baseline (biopsy); immediately prior to seeing the physician for biopsy results (pre- encounter); one week following the physician visit (post-encounter). Outcome measures included treatment preference and treatment received, knowledge, preference for shared decision making, decision making process, and patients’ use and satisfaction with the DA. Results Participants who received the simple DA had greater interest in shared decision making after reading the DA (p = 0.03), found the DA more helpful (p’s < 0.01) and were more likely to be considering watchful waiting (p = 0.03) compared to those receiving the complex DA at Time 2. While these differences were present before patients saw their urologists, there was no difference between groups in the treatment patients received.
Conclusions The simple DA led to increased desire for shared decision making and for less aggressive treatment. However, these differences disappeared following the physician visit, which appeared to change patients’ treatment preferences. Trial registration This trial was pre-registered prior to recruitment of participants. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01505-x.
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Affiliation(s)
- Angela Fagerlin
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA. .,Department of Population Health Sciences, University of Utah, 295 Chipeta Way Rm 1S105, Salt Lake City, UT, 84132, USA.
| | - Margaret Holmes-Rovner
- Center for Ethics and Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Timothy P Hofer
- Ann Arbor VA HSR&D Center for Practice Management and Outcomes Research, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - David Rovner
- Center for Ethics and Department of Medicine, Michigan State University, East Lansing, MI, USA
| | | | - Sara J Knight
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Bruce S Ling
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John T Wei
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Khaled Hafez
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Valerie C Kahn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, USA
| | - Daniel Connochie
- Ann Arbor VA HSR&D Center for Practice Management and Outcomes Research, Ann Arbor, MI, USA
| | - Jeffery Gingrich
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Peter A Ubel
- Sanford School of Public Policy, Duke University, Durham, NC, USA.,Fuqua School of Business, Duke University, Durham, USA
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21
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Yin S, Arkes HR, McCoy JP, Cohen ME, Mellers BA. Conflicting Goals Influence Physicians' Expressed Beliefs to Patients and Colleagues. Med Decis Making 2021; 41:505-514. [PMID: 33764191 DOI: 10.1177/0272989x211001841] [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: 11/16/2022]
Abstract
BACKGROUND Physicians who communicate their prognostic beliefs to patients must balance candor against other competing goals, such as preserving hope, acknowledging the uncertainty of medicine, or motivating patients to follow their treatment regimes. OBJECTIVE To explore possible differences between the beliefs physicians report as their own and those they express to patients and colleagues. DESIGN An online panel of 398 specialists in internal medicine who completed their medical degrees and practiced in the United States provided their estimated diagnostic accuracy and prognostic assessments for a randomly assigned case. In addition, they reported the diagnostic and prognostic assessments they would report to patients and colleagues more generally. Physicians answered questions about how and why their own beliefs differed from their expressed beliefs to patients and colleagues in the specific case and more generally in their practice. RESULTS When discussing beliefs about prognoses to patients and colleagues, most physicians expressed beliefs that differed from their own beliefs. Physicians were more likely to express greater optimism when talking to patients about poor prognoses than good prognoses. Physicians were also more likely to express greater uncertainty to patients when prognoses were poor than when they were good. The most common reasons for the differences between physicians' own beliefs and their expressed beliefs were preserving hope and acknowledging the inherent uncertainty of medicine. CONCLUSION To balance candor against other communicative goals, physicians tended to express beliefs that were more optimistic and contained greater uncertainty than the beliefs they said were their own, especially in discussions with patients whose prognoses were poor.
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Affiliation(s)
- Siyuan Yin
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Hal R Arkes
- Department of Psychology, Ohio State University, Columbus, OH, USA.,The Harding Center for Risk Literacy, Berlin, Germany
| | - John P McCoy
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Margot E Cohen
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara A Mellers
- Department of Psychology and Department of Marketing, University of Pennsylvania, Philadelphia, PA, USA
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22
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Nakayama K, Osaka W, Matsubara N, Takeuchi T, Toyoda M, Ohtake N, Uemura H. Shared decision making, physicians' explanations, and treatment satisfaction: a cross-sectional survey of prostate cancer patients. BMC Med Inform Decis Mak 2020; 20:334. [PMID: 33317523 PMCID: PMC7734751 DOI: 10.1186/s12911-020-01355-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 11/30/2020] [Indexed: 11/16/2022] Open
Abstract
Background Hormone therapy is one option for some types of prostate cancer. Shared decision making (SDM) is important in the decision making process, but SDM between prostate cancer patients receiving hormone therapy and physicians is not fully understood. This study tested hypotheses: “Patients’ perception of SDM is associated with treatment satisfaction, mediated by satisfaction with physicians’ explanations and perceived effective decision making” and “The amount of information provided to patients by physicians on diseases and treatment is associated with treatment satisfaction mediated by patients’ perceived SDM and satisfaction with physicians’ explanations.” Methods This cross-sectional study was conducted using an online panel via a private research company in Japan. The participants in this study were patients registered with the panel who had received or were currently receiving hormone therapy for prostate cancer and physicians registered with the panel who were treating patients with prostate cancer. Measures used in this study included a nine-item Shared Decision Making Questionnaire, levels of satisfaction with physicians’ explanations and treatment satisfaction, and effective decision making for patients (feeling the choice is informed, value-based, likely to be implemented and expressing satisfaction with the choice), and a Shared Decision Making Questionnaire for Doctors. The hypotheses were examined using path analysis. Results In total, 124 patients and 150 physicians were included in the analyses. In keeping with our hypotheses, perceived SDM significantly correlated with the physicians’ explanations and perceived effective decision making for patients, and satisfaction with physicians’ explanations and perceived effective decision making for patients were both related to treatment satisfaction. Although the amount of information provided to patients was correlated with the perceived SDM, it was indirectly related to their satisfaction with physicians’ explanations. Conclusions When physicians encourage patients to be actively involved in making decisions about treatment through the SDM process while presenting a wide range of information at the start of hormone therapy, patients’ effective decision making and physicians’ explanations may be improved; consequently, the patients’ overall treatment satisfaction may be improved. Physicians who treat patients with prostate cancer may have underestimated the importance of SDM before starting hormone therapy, even greater extent than patients.
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Affiliation(s)
- Kazuhiro Nakayama
- Graduate School of Nursing Science, St. Luke's International University, 10-1 Akashi-cho, Chuo-ku, Tokyo, 104-0044, Japan.
| | - Wakako Osaka
- Faculty of Nursing and Medical Care, Keio University, Tokyo, Japan.,The Jikei University School of Medicine, School of Nursing, Tokyo, Japan
| | - Nobuaki Matsubara
- Department of Breast and Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | | | | | | | - Hiroji Uemura
- Department of Urology and Renal Transplantation, Yokohama City University Medical Center, Yokohama, Japan
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Lane GI, Ellimoottil C, Wallner L, Meeks W, Mbassa R, Clemens JQ. Shared Decision-making in Urologic Practice: Results From the 2019 AUA Census. Urology 2020; 145:66-72. [PMID: 32771404 PMCID: PMC7658013 DOI: 10.1016/j.urology.2020.06.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/31/2020] [Accepted: 06/28/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To establish the rates of self-reported shared decision-making (SDM) and decision aid use among practicing urologists. Additionally, we aim to determine the practice factors that influence SDM use. MATERIALS AND METHODS This study uses data from the 2019 American Urological Association Annual Census SDM module. Urologists were presented with a rubric of 7 preference sensitive clinical situations and asked to choose the elements of SDM that they regularly use for the diagnosis. Multivariable logistic regression models were fit to evaluate factors contributing to the use of SDM. RESULTS Two thousand two hundred and nineteen urologists responded. Of these, 77% reported that they regularly use SDM in at least 1 preference sensitive clinical scenario. Between 40% and 58% regularly gave patients decision aids. Urologists who reported barriers to SDM had a decreased odds of reporting SDM (adjusted odds ratio OR [aOR] 0.80 [95% confidence interval [CI] 0.71-0.91]). Those practicing in academic settings (aOR 0.78 [95% CI 0.69-0.88]) were less likely than those in private practice to report SDM use. The number of patient visits per week was inversely associated with SDM use, with greater than 76 visits per week having decreased odds (aOR 0.65 [95% CI 0.57-0.74]). CONCLUSION In this sample of practicing urologists in the United States, the majority report regularly using SDM. However, rates of SDM varied by training, practice setting and clinical volume. Our findings highlight specific opportunities to improve in SDM in urology.
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Affiliation(s)
| | | | - Lauren Wallner
- Department of Urology, University of Michigan, Ann Arbor, MI
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24
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Engl T, Mandel P, Hoeh B, Preisser F, Wenzel M, Humke C, Welte M, Köllermann J, Wild P, Deuker M, Kluth LA, Roos FC, Chun FKH, Becker A. Impact of "Time-From-Biopsy-to-Prostatectomy" on Adverse Oncological Results in Patients With Intermediate and High-Risk Prostate Cancer. Front Surg 2020; 7:561853. [PMID: 33102515 PMCID: PMC7545071 DOI: 10.3389/fsurg.2020.561853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/21/2020] [Indexed: 01/12/2023] Open
Abstract
Objective: Many patients with localized prostate cancer (PCa) do not immediately undergo radical prostatectomy (RP) after biopsy confirmation. The aim of this study was to investigate the influence of “time-from-biopsy-to- prostatectomy” on adverse pathological outcomes. Materials and Methods: Between January 2014 and December 2019, 437 patients with intermediate- and high risk PCa who underwent RP were retrospectively identified within our prospective institutional database. For the aim of our study, we focused on patients with intermediate- (n = 285) and high-risk (n = 151) PCa using D'Amico risk stratification. Endpoints were adverse pathological outcomes and proportion of nerve-sparing procedures after RP stratified by “time-from-biopsy-to-prostatectomy”: ≤3 months vs. >3 and < 6 months. Medians and interquartile ranges (IQR) were reported for continuously coded variables. The chi-square test examined the statistical significance of the differences in proportions while the Kruskal-Wallis test was used to examine differences in medians. Multivariable (ordered) logistic regressions, analyzing the impact of time between diagnosis and prostatectomy, were separately run for all relevant outcome variables (ISUP specimen, margin status, pathological stage, pathological nodal status, LVI, perineural invasion, nerve-sparing). Results: We observed no difference between patients undergoing RP ≤3 months vs. >3 and <6 months after diagnosis for the following oncological endpoints: pT-stage, ISUP grading, probability of a positive surgical margin, probability of lymph node invasion (LNI), lymphovascular invasion (LVI), and perineural invasion (pn) in patients with intermediate- and high-risk PCa. Likewise, the rates of nerve sparing procedures were 84.3 vs. 87.4% (p = 0.778) and 61.0% vs. 78.8% (p = 0.211), for intermediate- and high-risk PCa patients undergoing surgery after ≤3 months vs. >3 and <6 months, respectively. In multivariable adjusted analyses, a time to surgery >3 months did not significantly worsen any of the outcome variables in patients with intermediate- or high-risk PCa (all p > 0.05). Conclusion: A “time-from-biopsy-to-prostatectomy” of >3 and <6 months is neither associated with adverse pathological outcomes nor poorer chances of nerve sparing RP in intermediate- and high-risk PCa patients.
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Affiliation(s)
- Tobias Engl
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany.,Urogate Associates, Frankfurt am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany.,Urogate Associates, Frankfurt am Main, Germany
| | - Felix Preisser
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Clara Humke
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maria Welte
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jens Köllermann
- Department of Pathology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Peter Wild
- Department of Pathology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marina Deuker
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Frederik C Roos
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
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Radiation oncologists' attitudes and beliefs about intensity-modulated radiation therapy and stereotactic body radiation therapy for prostate cancer. BMC Health Serv Res 2020; 20:796. [PMID: 32843034 PMCID: PMC7449079 DOI: 10.1186/s12913-020-05656-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 08/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background To better understand how radiation oncologists perceive intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for prostate cancer and how these perceptions may influence treatment decisions. Methods We conducted semi-structured interviews of radiation oncologists between January–May, 2016. We used a purposeful sampling technique to select participants across a wide range of experience, regions, and practice types. Two trained qualitative researchers used an inductive, iterative approach to code transcripts and identify themes. We then used content analysis and thematic analysis of the coded transcripts to understand radiation oncologists’ attitudes and beliefs about IMRT and SBRT. Results Thematic saturation was achieved after 20 interviews. Participants were affiliated with academic (n = 13; 65%), private (n = 5; 25%), and mixed (n = 2; 10%) practices and had a wide range of clinical experience (median 19 years; range 4–49 years). Analysis of interview transcripts revealed four general themes: 1) most radiation oncologists offered surgery, brachytherapy, IMRT, and active surveillance for low-risk patients; 2) there was no consensus on the comparative effectiveness of IMRT and SBRT; 3) key barriers to adopting SBRT included issues related to insurance, reimbursement, and practice inertia; and 4) despite these barriers, most participants envisioned SBRT use increasing over the next 5–10 years. Conclusions In the absence of strong opinions about effectiveness, nonclinical factors influence the choice of radiation treatment. Despite a lack of consensus, most participants agreed SBRT may become a standard of care in the future.
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Langford AT, Scherer LD, Ubel PA, Holmes-Rovner M, Scherr KA, Fagerlin A. Racial differences in veterans' response to a standard vs. patient-centered decision aid for prostate cancer: Implications for decision making in African American and White men. PATIENT EDUCATION AND COUNSELING 2020; 103:S0738-3991(20)30322-0. [PMID: 32591257 DOI: 10.1016/j.pec.2020.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To determine whether racial differences exist in patient preferences for prostate cancer treatment after being informed about options using a patient-centered vs. a standard decision aid (DA). METHODS This article reports secondary analyses of a large study of men diagnosed with early stage prostate cancer. Men were recruited from 4 VA Health Systems and randomized to receive a patient-centered or standard DA about prostate cancer treatment options. Data were collected at 1) baseline, 2) after reading the DA but prior to diagnosis, and 3) after receiving a cancer diagnosis and meeting with a urologist. RESULTS White patients who received the patient-centered DA written at a 7th grade reading level were more likely to prefer active surveillance and less likely to prefer radiation compared to those who received the standard DA written at >9th grade reading level. African American patients' treatment preferences did not differ as a function of DA. CONCLUSIONS When informed about prostate cancer treatment options through a patient-centered DA, White patients changed their treatment preferences but African American patients did not. PRACTICE IMPLICATIONS As DAs are increasingly being used in clinical practice, more research is needed regarding the efficacy, relevance, and receptivity of DAs for African Americans.
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Affiliation(s)
- Aisha T Langford
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA; Clinical and Translational Science Institute, New York University Grossman School of Medicine, New York, NY, USA.
| | - Laura D Scherer
- Division of Cardiology, University of Colorado School of Medicine, Denver, CO, USA; Colorado Program for Patient Centered Decisions at ACCORDS, University of Colorado School of Medicine, Denver, CO, USA
| | - Peter A Ubel
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Margaret Holmes-Rovner
- Center for Ethics and Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Karen A Scherr
- Fuqua School of Business, Duke University, Durham, NC, USA; Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA; Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
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27
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Matsen CB, Ray D, Kaphingst KA, Zhang C, Presson AP, Finlayson SRG. Patient Satisfaction With Decision Making Does Not Correlate With Patient Centeredness of Surgeons. J Surg Res 2020; 246:411-418. [PMID: 31635834 DOI: 10.1016/j.jss.2019.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/09/2019] [Accepted: 09/13/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-quality decision making is important in patient-centered care. Although patient involvement in decision making varies widely, most patients desire to share in decision making. The Press-Ganey Patient Satisfaction survey includes questions that measure patients' perceptions of their providers' efforts to involve them in decision making (PGDM). We hypothesized that higher PGDM scores would correlate with higher scores on a validated measure of patient centeredness. MATERIALS AND METHODS Surgical providers at a university hospital who routinely receive Press-Ganey scores received a survey that included the Patient-Practitioner Orientation Scale (PPOS), a validated tool that measures the provider's orientation toward patient centeredness on a continuous six-point scale: score ≥5 = high, 4.57-5 = moderate, and <4.57 = low and includes nine-item "caring" or "sharing" subscales. We compared PPOS scores to PGDM scores, averaged from April 2015 to January 2016. RESULTS Eighty-six of 112 (75%) of surgical providers responded to the survey. Fifty-two (46%) had PGDM scores available and 26% achieved a perfect score on the PGDM. The overall PPOS scores were low, with a mean of 4.2 (SD = 0.5). The PPOS was not correlated with the PGDM, correlation coefficient (rs) = -0.07 (CI: -0.34-0.21, P = 0.63). Similarly, the two subscales of the PPOS did not correlate with the PGDM with rs = -0.15 (CI: -0.41-0.13, P = 0.29) for "caring" and rs = -0.04 (CI: -0.31-0.23, P = 0.76) for "sharing". CONCLUSIONS Although surgical providers scored low in patient centeredness using the PPOS, over one-quarter (26%) of them rank in the top 1% on the PGDM. No correlation was found between providers' patient centeredness and their patients' perceptions of efforts to include them in decision making.
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Affiliation(s)
- Cindy B Matsen
- Department of Surgery, University of Utah, Salt Lake City, Utah.
| | - David Ray
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Kimberly A Kaphingst
- Department of Communication, University of Utah College of Humanities, Salt Lake City, Utah
| | - Chong Zhang
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
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Abstract
OBJECTIVES Shared decision-making (SDM) is the gold standard approach to cancer treatment decision-making in the 21st century, but it is frequently misunderstood, and many clinicians do not know how to operationalize the SDM framework in their busy practices. Here we review the principles behind SDM, discuss unique aspects of acute myeloid leukemia (AML) that complicate the decision-making process, and provide one recommended framework for how to implement SDM into practice. DATA SOURCES Published literature and clinical experiences. CONCLUSION AML poses unique challenges to treatment decision-making. These challenges can be effectively addressed by following the SDM framework in practice. IMPLICATIONS FOR NURSING PRACTICE Nurses can play an important role in the AML treatment decision-making process. Being on the front lines of care, working most directly with patients and families, nurses are best positioned to assess understanding after treatment discussions take place, detect emotional distress, and provide empathic support as part of the SDM process.
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Affiliation(s)
- Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Cancer Institute, Durham, NC.
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29
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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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30
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Sharma RK, Cameron KA, Zech JM, Jones SF, Curtis JR, Engelberg RA. Goals-of-Care Decisions by Hospitalized Patients With Advanced Cancer: Missed Clinician Opportunities for Facilitating Shared Decision-Making. J Pain Symptom Manage 2019; 58:216-223. [PMID: 31100320 PMCID: PMC9911137 DOI: 10.1016/j.jpainsymman.2019.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/30/2019] [Accepted: 05/05/2019] [Indexed: 01/09/2023]
Abstract
CONTEXT Hospitalized patients with advanced cancer often face complex, preference-sensitive decisions. How clinicians and patients engage in shared decision-making during goals-of-care discussions is not well understood. OBJECTIVE The objective of this study was to explore decision-making by patients and clinicians during inpatient goals-of-care discussions. METHODS This is a qualitative study of audio-recorded goals-of-care discussions between hospitalized patients with advanced cancer and their clinicians. Grounded theory was used to analyze transcripts. RESULTS Sixty-two patients participated in goals-of-care discussions with 51 unique clinicians. Nearly half of patients (n = 30) were female and their mean age was 60.1 years (SD = 12.7). A palliative care attending or fellow was present in 58 of the 62 discussions. Decisions centered on three topics: 1) disease-modifying treatments; 2) hospice; and 3) code status. Clinicians' approach to decision-making included the following stages: "information exchange," "deliberation," "making a patient-centered recommendation," and "wrap-up: decisional status." Successful completion of each stage varied by the type of decision. When discussing code status, clinicians missed opportunities to engage patients in information exchange and to wrap up decisional status. By contrast, clinicians discussing disease-modifying treatments and hospice failed to integrate patient preferences. Clinicians also missed opportunities to make patient-centered recommendations when discussing treatment decisions. CONCLUSION Clinicians missed opportunities to facilitate shared decision-making regarding goals of care, and these missed opportunities differed by type of decision being discussed. Opportunities for clinician communication training include engagement in collaborative deliberation with patients and making patient-centered recommendations in situations of high medical uncertainty.
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Affiliation(s)
- Rashmi K Sharma
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Kenzie A Cameron
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, Illinois, USA
| | - Jennifer M Zech
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Sasha F Jones
- Division of Hospital Medicine, Northwestern University, Chicago, Illinois, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
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Assessment of men's risk thresholds to proceed with prostate biopsy for the early detection of prostate cancer. Int Urol Nephrol 2019; 51:1297-1302. [PMID: 31187423 DOI: 10.1007/s11255-019-02196-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/04/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE To delineate the range of "risk thresholds" for prostate biopsy to determine how improved prostate cancer (CaP) risk prediction tools may impact shared decision-making (SDM). METHODS We conducted a cross-sectional survey study involving men 45-75 years old attending a multispecialty urology clinic. Data included demographics, personal and family prostate cancer history, and prostate biopsy history. Respondents were presented with a summary of the details, risks, and benefits of prostate biopsy, then asked to indicate the specific risk threshold (% chance) of high-grade CaP at which they would proceed with prostate biopsy. RESULTS Of a total of 103 respondents, 18 men (17%) had a personal history of CaP, and 31 (30%) had undergone prostate biopsy. The median risk threshold to proceed with prostate biopsy was 25% (interquartile range 10-50%). Risk thresholds did not vary by race, education, or employment. Personal history of CaP or prostate biopsy was significantly associated with lower mean risk thresholds (19% vs. 32% [P = 0.02] and 23% vs. 33% [P = 0.04], respectively). In the lowest versus highest risk threshold quartiles, there were significantly higher rates of CaP (36% vs. 1%, P = 0.01) and prior prostate biopsy (46% vs. 17%, P < 0.01). CONCLUSIONS Men have a wide range of risk thresholds for high-grade CaP to proceed with prostate biopsy. Men with a prior history of CaP or biopsy reported lower risk thresholds, which may reflect their greater concern for this disease. The extent to which refined risk prediction tools will improve SDM warrants further study.
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32
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McCaffery K, Nickel B, Pickles K, Moynihan R, Kramer B, Barratt A, Hersch J. Resisting recommended treatment for prostate cancer: a qualitative analysis of the lived experience of possible overdiagnosis. BMJ Open 2019; 9:e026960. [PMID: 31122983 PMCID: PMC6537980 DOI: 10.1136/bmjopen-2018-026960] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To describe the lived experience of a possible prostate cancer overdiagnosis in men who resisted recommended treatment. DESIGN Qualitative interview study SETTING: Australia PARTICIPANTS: 11 men (aged 59-78 years) who resisted recommended prostate cancer treatment because of concerns about overdiagnosis and overtreatment. OUTCOMES Reported experience of screening, diagnosis and treatment decision making, and its impact on psychosocial well-being, life and personal circumstances. RESULTS Men's accounts revealed profound consequences of both prostate cancer diagnosis and resisting medical advice for treatment, with effects on their psychological well-being, family, employment circumstances, identity and life choices. Some of these men were tested for prostate-specific antigen without their knowledge or informed consent. The men felt uninformed about their management options and unsupported through treatment decision making. This often led them to develop a sense of disillusionment and distrust towards the medical profession and conventional medicine. The findings show how some men who were told they would soon die without treatment (a prognosis which ultimately did not eventuate) reconciled issues of overdiagnosis and potential overtreatment with their own diagnosis and situation over the ensuing 1 to 20+ years. CONCLUSIONS Men who choose not to have recommended treatment for prostate cancer may avoid treatment-associated harms like incontinence and impotence, however our findings showed that the impact of the diagnosis itself is immense and far-reaching. A high priority for improving clinical practice is to ensure men are adequately informed of these potential consequences before screening is considered.
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Affiliation(s)
- Kirsten McCaffery
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kristen Pickles
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ray Moynihan
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Barnett Kramer
- National Cancer Institute Division of Cancer Prevention, Bethesda, Maryland, USA
| | - Alexandra Barratt
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Scalia P, Durand MA, Berkowitz JL, Ramesh NP, Faber MJ, Kremer JAM, Elwyn G. The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis. PATIENT EDUCATION AND COUNSELING 2019; 102:817-841. [PMID: 30612829 DOI: 10.1016/j.pec.2018.12.020] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows. METHODS Databases were systematically searched for RCTs of encounter PDAs to enable the conduct of a meta-analysis. We used a framework analysis approach to conduct a narrative synthesis of non-randomized studies. RESULTS We included 23 RCTs and 30 non-randomized studies. Encounter PDAs significantly increased knowledge (SMD = 0.42; 95% CI 0.30, 0.55), lowered decisional conflict (SMD= -0.33; 95% CI -0.56, -0.09), increased observational-based assessment of shared decision making (SMD = 0.94; 95% CI 0.40, 1.48) and satisfaction with the decision-making process (OR = 1.78; 95% CI 1.19, 2.66) without increasing visit durations (SMD= -0.06; 95% CI -0.29, 0.16). The narrative synthesis showed that encounter tools have high utility for patients and clinicians, yet important barriers to implementation exist (i.e. time constraints) at the clinical and organizational level. CONCLUSION Encounter PDAs have a positive impact on patient-clinician collaboration, despite facing implementation barriers. PRACTICAL IMPLICATIONS The potential utility of encounter PDAs requires addressing the systemic and structural barriers that prevent adoption in clinical practice.
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Affiliation(s)
- Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Julia L Berkowitz
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Nithya P Ramesh
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marjan J Faber
- Radboud university medical center, Scientific Institute for Quality of Healthcare, PO Box 9101, Nijmegen, 6500, HB, the Netherlands.
| | - Jan A M Kremer
- Radboud university medical center, Scientific Institute for Quality of Healthcare, PO Box 9101, Nijmegen, 6500, HB, the Netherlands.
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Broughman JR, Basak R, Nielsen ME, Reeve BB, Usinger DS, Spearman KC, Godley PA, Chen RC. Prostate Cancer Patient Characteristics Associated With a Strong Preference to Preserve Sexual Function and Receipt of Active Surveillance. J Natl Cancer Inst 2019; 110:420-425. [PMID: 29045679 PMCID: PMC6367921 DOI: 10.1093/jnci/djx218] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 09/18/2017] [Indexed: 11/13/2022] Open
Abstract
Background Men with early-stage prostate cancer have multiple options that have similar oncologic efficacy but vary in terms of their impact on quality of life. In low-risk cancer, active surveillance is the option that best preserves patients' sexual function, but it is unknown if patient preference affects treatment selection. Our objectives were to identify patient characteristics associated with a strong preference to preserve sexual function and to determine whether patient preference and baseline sexual function level are associated with receipt of active surveillance in low-risk cancer. Methods In this population-based cohort of men with localized prostate cancer, baseline patient-reported sexual function was assessed using a validated instrument. Patients were also asked whether preservation of sexual function was very, somewhat, or not important. Prostate cancer disease characteristics and treatments received were abstracted from medical records. A modified Poisson regression model with robust standard errors was used to compute adjusted risk ratio (aRR) estimates. All statistical tests were two-sided. Results Among 1194 men, 52.6% indicated a strong preference for preserving sexual function. Older men were less likely to have a strong preference (aRR = 0.98 per year, 95% confidence interval [CI] = 0.97 to 0.99), while men with normal sexual function were more likely (vs poor function, aRR = 1.59, 95% CI = 1.39 to 1.82). Among 568 men with low-risk cancer, there was no clear association between baseline sexual function or strong preference to preserve function with receipt of active surveillance. However, strong preference may differnetially impact those with intermediate baseline function vs poor function (Pinteraction = .02). Conclusions Treatment choice may not always align with patients' preferences. These findings demonstrate opportunities to improve delivery of patient-centered care in early prostate cancer.
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Affiliation(s)
- James R Broughman
- Department of Radiation, Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.,School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ramsankar Basak
- Department of Radiation, Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology and Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bryce B Reeve
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology and Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deborah S Usinger
- Department of Radiation, Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kiayni C Spearman
- Department of Radiation, Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paul A Godley
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ronald C Chen
- Department of Radiation, Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.,School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Skolarus TA, Hawley ST, Wittmann DA, Forman J, Metreger T, Sparks JB, Zhu K, Caram MEV, Hollenbeck BK, Makarov DV, Leppert JT, Shelton JB, Shahinian V, Srinivasaraghavan S, Sales AE. De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT). Implement Sci 2018; 13:144. [PMID: 30486836 PMCID: PMC6262964 DOI: 10.1186/s13012-018-0833-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 01/27/2023] Open
Abstract
Background Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial. Methods/design This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. Discussion Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring. Trial registration ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA. .,Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Kevin Zhu
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Megan E V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danil V Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center, New York City, NY, USA.,VA New York Harbor Healthcare System, 423 E. 23rd St, New York City, NY, 10010, USA
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Grant Building, S-287, 300 Pasteur Drive, Stanford, CA, 94305, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Jeremy B Shelton
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Vahakn Shahinian
- Division of Nephrology, University of Michigan Medical School, Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | | | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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Andkhoie M, Meyer D, Szafron M. Factors underlying treatment decision-making for localized prostate cancer in the U.S. and Canada: A scoping review using principal component analysis. Can Urol Assoc J 2018; 13:E220-E225. [PMID: 30472985 DOI: 10.5489/cuaj.5538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this research is to gather, collate, and identify key factors commonly studied in localized prostate cancer (LPC) treatment decision-making in Canada and the U.S. METHODS This scoping review uses five databases (Medline, EMBASE, CINAHL, AMED, and PsycInfo) to identify relevant articles using a list of inclusion and exclusion criteria applied by two reviewers. A list of topics describing the themes of the articles was extracted and key factors were identified using principal component analysis (PCA). A word cloud of titles and abstracts of the relevant articles was created to identify complementary results to the PCA. RESULTS This review identified 77 relevant articles describing 32 topics related to LPC treatment decision-making. The PCA grouped these 32 topics into five key factors commonly studied in LPC treatment decision-making: 1) treatment type; 2) socioeconomic/demographic characteristics; 3) personal reasons for treatment choice; 4) psychology of treatment decision experience; and 5) level of involvement in the decision-making process. The word cloud identified common phrases that were complementary to the factors identified through the PCA. CONCLUSIONS This research identifies several possible factors impacting LPC treatment decision-making. Further research needs to be completed to determine the impact that these factors have in the LPC treatment decision-making experience.
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Affiliation(s)
- Mustafa Andkhoie
- School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada
| | - Desneige Meyer
- School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada
| | - Michael Szafron
- School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada
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Makarov DV, Holmes-Rovner M, Rovner DR, Averch T, Barry MJ, Chrouser K, Gee WF, Goodrich K, Haynes M, Krahn M, Saigal C, Sox HC, Stacey D, Tessier C, Waterhouse RL, Fagerlin A. Quality Improvement Summit 2016: Shared Decision Making and Prostate Cancer Screening. UROLOGY PRACTICE 2018. [DOI: 10.1016/j.urpr.2017.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Danil V. Makarov
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | | | - David R. Rovner
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Timothy Averch
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Michael J. Barry
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Kristin Chrouser
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - William F. Gee
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Kate Goodrich
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Mike Haynes
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Murray Krahn
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Christopher Saigal
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Harold C. Sox
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Dawn Stacey
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Christopher Tessier
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Robert L. Waterhouse
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Angela Fagerlin
- American Urological Association Education and Research Inc., Linthicum, Maryland
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Personalized Approach and Precision Medicine in Supportive and End-of-Life Care for Patients With Advanced and End-Stage Kidney Disease. Semin Nephrol 2018; 38:336-345. [PMID: 30082054 DOI: 10.1016/j.semnephrol.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Kidney supportive care requires a highly personalized approach to care. Precision medicine holds promise for a deeper understanding of the pathophysiology of symptoms and related syndromes and more precise individualization of prognosis and treatment estimates, therefore providing valuable opportunities for greater personalization of supportive care. However, the major drivers of quality of life are psychosocial, economic, lifestyle, and preference-based, and consideration of these factors and skilled communication are integral to the provision of excellent and personalized kidney supportive care. This article discusses the concepts of personalized and precision medicine in the context of kidney supportive care and highlights some opportunities and limitations within these fields.
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Tentori K, Pighin S, Divan C, Crupi V. Mind the gap: Physicians' assessment of patients' importance weights in localized prostate cancer. PLoS One 2018; 13:e0200780. [PMID: 30048485 PMCID: PMC6062014 DOI: 10.1371/journal.pone.0200780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The management of localized prostate cancer is challenging because of the many therapeutic options available, none of which is generally acknowledged as superior to the others in every respect. The selection of the most appropriate treatment should therefore reflect patients' preferences. OBJECTIVE The purpose of the following study was to pilot a new approach for investigating whether urologists who had previously provided patients with therapeutic advice actually knew their patients' importance weights concerning the relevant aspects of the treatments at issue. METHOD Participants were patients recently diagnosed with localized prostate cancer (n = 20), urologists (n = 10), and non-medical professionals (architects, n = 10). These last served as a control group for the urologists and were matched to them for age and gender. Patients' importance weights were elicited by two standard methods (Direct Rating and Value Hierarchy). Each urologist was asked to estimate (with Direct Rating) his/her patient's importance weights. The same task was performed by a corresponding architect, who never met the patient and knew only the patient's age. Univariate and bivariate statistical analyses were performed to investigate the association between importance weights as elicited from patients and as estimated by urologists and architects, as well as to assess whether such agreement was attribute-dependent. RESULTS Participants found both elicitation methods easy to use. The correlation between patients' actual importance weights and urologists' estimates was poor and comparable to that obtained between patients and architects. This result did not depend on the attribute considered, with the sole exception of the attribute "Effectiveness in curing the cancer", which was evaluated as the most important attribute by the majority of participants. CONCLUSION These findings demonstrate the feasibility of the employed methodology and highlight the need to support preference-sensitive decisions in clinical practice by facilitating the elicitation of patients' importance weights, as well as their communication to physicians.
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Affiliation(s)
- Katya Tentori
- Center for Mind/Brain Sciences, University of Trento, Trento, Italy
| | - Stefania Pighin
- Center for Mind/Brain Sciences, University of Trento, Trento, Italy
| | - Claudio Divan
- Urology Division of the Santa Chiara Hospital, Trento, Italy
| | - Vincenzo Crupi
- Department of Philosophy and Educational Sciences, University of Torino, Torino, Italy
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Légaré F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner‐Banzhoff N. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2018; 7:CD006732. [PMID: 30025154 PMCID: PMC6513543 DOI: 10.1002/14651858.cd006732.pub4] [Citation(s) in RCA: 221] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review. OBJECTIVES To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies. SELECTION CRITERIA Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs. AUTHORS' CONCLUSIONS It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.
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Affiliation(s)
- France Légaré
- Université LavalCentre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL‐UL)2525, Chemin de la CanardièreQuebecQuébecCanadaG1J 0A4
| | - Rhéda Adekpedjou
- Université LavalDepartment of Social and Preventive MedicineQuebec CityQuebecCanada
| | - Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | - Stéphane Turcotte
- Centre de Recherche du CHU de Québec (CRCHUQ) ‐ Hôpital St‐François d'Assise10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Jennifer Kryworuchko
- The University of British ColumbiaSchool of NursingT201 2211 Wesbrook MallVancouverBritish ColumbiaCanadaV6T 2B5
| | - Ian D Graham
- University of OttawaSchool of Epidemiology, Public Health and Preventative Medicine600 Peter Morand CrescentOttawaONCanada
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Mary C Politi
- Washington University School of MedicineDivision of Public Health Sciences, Department of Surgery660 S Euclid AveSt LouisMissouriUSA63110
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Glyn Elwyn
- Cardiff UniversityCochrane Institute of Primary Care and Public Health, School of Medicine2nd Floor, Neuadd MeirionnyddHeath ParkCardiffWalesUKCF14 4YS
| | - Norbert Donner‐Banzhoff
- University of MarburgDepartment of Family Medicine / General PracticeKarl‐von‐Frisch‐Str. 4MarburgGermanyD‐35039
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Brooks JV, Ellis SD, Morrow E, Kimminau KS, Thrasher JB. Patient Factors That Influence How Physicians Discuss Active Surveillance With Low-Risk Prostate Cancer Patients: A Qualitative Study. Am J Mens Health 2018; 12:1719-1727. [PMID: 29973123 PMCID: PMC6142114 DOI: 10.1177/1557988318785741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For men diagnosed with prostate cancer, making treatment decisions can be overwhelming. Navigating treatment options, along with potential treatment side effects, can be difficult, and patients often rely heavily on the advice of their physicians. This study was aimed at understanding more about the way urologists talk with their patients about one treatment option: active surveillance (AS), a recognized management strategy for men with low-risk prostate cancer that includes close observation and monitoring of the cancer. This study reports, through 22 interviews with urologists, that urologists believe patients are hesitant about AS for a number of reasons, including misperceptions about cancer severity, anxiety, aversion to repeated biopsies that accompany AS, or family member preferences. Because urologists play an influential role in educating patients about treatment options, the discussion around AS can be impacted by barriers that physicians believe matter for their patients. Improving awareness among urologists about what factors impact their patient education about low-risk prostate cancer is important. Identifying tools to improve shared decision making in this area could result in treatment decisions that are increasingly concordant with patients' values, concerns, and goals.
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Affiliation(s)
- Joanna Veazey Brooks
- 1 Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shellie D Ellis
- 1 Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, KS, USA
| | - Emily Morrow
- 2 Department of Sociology, University of Kansas, Lawrence, KS, USA
| | - Kim S Kimminau
- 1 Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, KS, USA.,3 Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - J Brantley Thrasher
- 4 Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
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Impact of a web-based prostate cancer treatment decision aid on patient-reported decision process parameters: results from the Prostate Cancer Patient Centered Care trial. Support Care Cancer 2018; 26:3739-3748. [PMID: 29752528 PMCID: PMC6182363 DOI: 10.1007/s00520-018-4236-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 04/26/2018] [Indexed: 01/27/2023]
Abstract
Purpose To compare patients’ evaluation of the treatment decision-making process in localized prostate cancer between counseling that included an online decision aid (DA) and standard counseling. Methods Eighteen Dutch hospitals were randomized to DA counseling (n = 235) or the control group with standard counseling (n = 101) in a pragmatic, cluster randomized controlled trial. The DA was provided to patients at, or soon after diagnosis. Decisional conflict, involvement, knowledge, and satisfaction with information were assessed with a questionnaire after treatment decision-making. Anxiety and depression served as covariates. Results The levels of decision involvement and conflict were comparable between patients in both groups. Patients with a DA felt more knowledgeable but scored equally well on a knowledge test as patients without a DA. Small significant negative effects were found on satisfaction with information and preparation for decision-making. A preference for print over online and depression and anxiety symptoms was negatively associated with satisfaction and conflict scores in the DA group. Discussion The DA aimed to support shared decision-making, while outcomes for a majority of DA users were comparable to patients who received standard counseling. Patients, who are less comfortable with the online DA format or experience anxiety or depression symptoms, could require more guidance toward shared decision-making. To evaluate long-term DA effects, follow-up evaluation on treatment satisfaction and decisional regret will be done.
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Filson CP. Quality of care and economic considerations of active surveillance of men with prostate cancer. Transl Androl Urol 2018; 7:203-213. [PMID: 29732278 PMCID: PMC5911536 DOI: 10.21037/tau.2017.08.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.g., quality) for acceptable costs. This review discusses quality of care considerations for men contemplating active surveillance, and highlights cost implications at the patient, health-system, and societal level related to pursuit of non-interventional management of men diagnosed with localized prostate cancer. In general, most quality measures are focused on prostate cancer care in general, rather that active surveillance patients specifically. However, most prostate cancer quality measures are pertinent to men seeking close observation of their prostate tumors with active surveillance. These include accurate documentation of clinical stage, informed discussion of all treatment options, and appropriate use of imaging for less-aggressive prostate cancer. Furthermore, interventions that may help improve the quality of care for active surveillance patients are reviewed (e.g., quality collaboratives, judicious antibiotic use, etc.). Finally, the potential economic impact and benefits of broad acceptance of active surveillance strategies are highlighted.
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Affiliation(s)
- Christopher P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta Veterans Administration Medical Center, Decatur, GA, USA
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44
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See, Do, Teach? A Review of Contemporary Literature and Call to Action for Communication Skills Teaching in Urology. Urology 2018; 114:33-40. [DOI: 10.1016/j.urology.2017.10.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 09/22/2017] [Accepted: 10/24/2017] [Indexed: 11/30/2022]
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Drummond FJ, Gavin AT, Sharp L. Incongruence in treatment decision making is associated with lower health-related quality of life among prostate cancer survivors: results from the PiCTure study. Support Care Cancer 2017; 26:1645-1654. [PMID: 29222597 DOI: 10.1007/s00520-017-3994-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/21/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE We investigated associations between treatment decision making (TDM) and global health-related-quality-of-life (gHRQoL) among prostate cancer (PCa) survivors. METHODS Postal questionnaires were sent to 6559 PCa survivors 2-18 years post-diagnosis, identified through population-based cancer registries in Ireland. The Control Preference Scale was used to investigate respondents' 'actual' and 'preferred' role in TDM. The TDM experience was considered 'congruent' when actual and preferred roles matched and 'incongruent' otherwise. The EORTC QLQ-C30 was used to measure gHRQoL. Multivariate linear regression was employed to investigate associations between (i) actual role in TDM, (ii) congruence in TDM, and gHRQoL. RESULTS The response rate was 54% (n = 3348). The percentages of men whose actual role in TDM was active, shared or passive were 36, 33 and 31%, respectively. Congruence between actual and preferred roles in TDM was 58%. Actual role in TDM was not associated with gHRQoL. In multivariate analysis, after adjusting for socio-demographic and clinical factors, survivors whose TDM experience was incongruent had significantly lower gHRQoL than those who had a congruent experience (- 2.25 95%CI - 4.09, - 0.42; p = 0.008). This effect was most pronounced among survivors who had more involvement in the TDM than they preferred (- 2.69 95%CI - 4.74, - 0.63; p = 0.010). CONCLUSIONS Less than 6 in 10 PCa survivors experienced congruence between their actual and preferred roles in TDM. Having an incongruent TDM experience was associated with lower gHRQoL among survivors. These findings suggest that involving patients in TDM to the degree to which they want to be involved may help improve PCa survivors' gHRQoL.
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Affiliation(s)
- Frances J Drummond
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Centre for Public Health, Queen's University Belfast, Mulhouse Building, Grosvenor Road, Belfast, BT12 6BJ, UK
| | - Linda Sharp
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
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Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:31-39. [PMID: 29111936 PMCID: PMC6312722 DOI: 10.1080/15265161.2017.1378753] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Many health care decisions depend not only upon medical facts, but also on value judgments-patient goals and preferences. Until recent decades, patients relied on doctors to tell them what to do. Then ethicists and others convinced clinicians to adopt a paradigm shift in medical practice, to recognize patient autonomy, by orienting decision making toward the unique goals of individual patients. Unfortunately, current medical practice often falls short of empowering patients. In this article, we reflect on whether the current state of medical decision making effectively promotes patients' health care goals. We base our reflections, in part, on research in which we observed physicians making earnest efforts to partner with patients in making treatment decisions, but still struggling to empower patients-failing to communicate clearly to patients about decision-relevant information, overwhelming patients with irrelevant information, overlooking when patients' emotions made it hard to engage in choices, and making recommendations before discussing patients' goals.
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Affiliation(s)
| | | | - Angela Fagerlin
- b University of Utah and VA Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS)
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van Stam MA, van der Poel HG, van der Voort van Zyp JR, Tillier CN, Horenblas S, Aaronson NK, Ruud Bosch J. The accuracy of patients’ perceptions of the risks associated with localised prostate cancer treatments. BJU Int 2017; 121:405-414. [DOI: 10.1111/bju.14034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marie-Anne van Stam
- Department of; Urology; University Medical Center Utrecht; Utrecht The Netherlands
- Division of Psychosocial Research and Epidemiology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Henk G. van der Poel
- Department of Urology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | | | - Corinne N. Tillier
- Department of Urology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Simon Horenblas
- Department of; Urology; University Medical Center Utrecht; Utrecht The Netherlands
- Department of Urology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Neil K. Aaronson
- Division of Psychosocial Research and Epidemiology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - J.L.H. Ruud Bosch
- Department of; Urology; University Medical Center Utrecht; Utrecht The Netherlands
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48
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Holmes-Rovner M, Srikanth A, Henry SG, Langford A, Rovner DR, Fagerlin A. Decision aid use during post-biopsy consultations for localized prostate cancer. Health Expect 2017; 21:279-287. [PMID: 28881105 PMCID: PMC5750733 DOI: 10.1111/hex.12613] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Decision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patient-clinician encounters. OBJECTIVE To characterize the content and communicative function of high-quality DAs during diagnostic clinic visits for prostate cancer. PARTICIPANTS 252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics. METHODS Qualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated. RESULTS Booklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physicians' explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decision-making. In regression analysis, predictors of booklet talk were fewer years of patient education (P = .027) and more time in the encounter (P = .027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk. CONCLUSIONS Results show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments.
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Affiliation(s)
- Margaret Holmes-Rovner
- Centre for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing, MI, USA.,Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Akshay Srikanth
- Henry Ford Hospital, Wayne State University, Detroit, MI, USA
| | - Stephen G Henry
- Division of General Medicine, Geriatrics, and Bioethics, University of California Davis, Sacramento, CI, USA
| | - Aisha Langford
- Department of Population Health, New York University School of Medicine, New York City, NY, USA
| | - David R Rovner
- Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Angela Fagerlin
- VA Ann Arbor Centre for Clinical Management Research, Department of Internal Medicine and Department of Psychology, University of Michigan, Ann Arbor, MI, USA
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Davis K, Bellini P, Hagerman C, Zinar R, Leigh D, Hoffman R, Aaronson D, Van Den Eeden S, Philips G, Taylor K. Physicians' Perceptions of Factors Influencing the Treatment Decision-making Process for Men With Low-risk Prostate Cancer. Urology 2017; 107:86-95. [PMID: 28454988 PMCID: PMC5880528 DOI: 10.1016/j.urology.2017.02.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/28/2017] [Accepted: 02/08/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess physicians' attitudes regarding multiple factors that may influence recommendations for active surveillance (AS) vs active treatment (AT) given the central role physicians play in the treatment decision-making process. MATERIALS AND METHODS We conducted semistructured interviews to assess factors that physicians consider important when recommending AS vs AT, as well as physicians' perceptions of what their patients consider important in the decision. Participants included urologists (N = 11), radiation oncologists (N = 12), and primary care physicians (N = 10) from both integrated and fee-for-service healthcare settings. RESULTS Across the specialties, quantitative data indicated that most physicians reported that their recommendations for AS were influenced by patients' older age, willingness and ability to follow a surveillance protocol, anxiety, comorbidities, life expectancy, and treatment preferences. Qualitative findings highlighted physicians' concerns about malpractice lawsuits, given the possibility of disease progression. Additionally, most physicians noted the role of the healthcare setting, suggesting that financial incentives may be associated with AT recommendations in fee-for-service settings. Finally, most physicians reported spouse or family opposition to AS due to their own anxiety or lack of understanding of AS. CONCLUSION We found that patient and physician preferences, healthcare setting, and family or spouse factors influence physicians' treatment recommendations for men with low-risk PCa. These were consistent themes across physician subspecialties in both an Health Maintenance Organization and in fee-for-service settings.
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Affiliation(s)
- Kimberly Davis
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC.
| | - Paula Bellini
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Charlotte Hagerman
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Riley Zinar
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Daniel Leigh
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Richard Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine/Iowa City VA Medical Center, Iowa City, IA
| | - David Aaronson
- Department of Urology, Kaiser Permanente, East Bay, Oakland, CA
| | | | - George Philips
- Department of Medicine, MedStar Georgetown University Hospital Center, Washington, DC
| | - Kathryn Taylor
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
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Hoffman RM, Van Den Eeden SK, Davis KM, Lobo T, Luta G, Shan J, Aaronson D, Penson DF, Leimpeter AD, Taylor KL. Decision-making processes among men with low-risk prostate cancer: A survey study. Psychooncology 2017; 27:325-332. [PMID: 28612468 DOI: 10.1002/pon.4469] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 04/17/2017] [Accepted: 06/02/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To characterize decision-making processes and outcomes among men expressing early-treatment preferences for low-risk prostate cancer. METHODS We conducted telephone surveys of men newly diagnosed with low-risk prostate cancer in 2012 to 2014. We analyzed subjects who had discussed prostate cancer treatment with a clinician and expressed a treatment preference. We asked about decision-making processes, including physician discussions, prostate-cancer knowledge, decision-making styles, treatment preference, and decisional conflict. We compared the responses across treatment groups with χ2 or ANOVA. RESULTS Participants (n = 761) had a median age of 62; 82% were white, 45% had a college education, and 35% had no comorbidities. Surveys were conducted at a median of 25 days (range 9-100) post diagnosis. Overall, 55% preferred active surveillance (AS), 26% preferred surgery, and 19% preferred radiotherapy. Participants reported routinely considering surgery, radiotherapy, and AS. Most were aware of their low-risk status (97%) and the option for AS (96%). However, men preferring active treatment (AT) were often unaware of treatment complications, including sexual dysfunction (23%) and urinary complications (41%). Most men (63%) wanted to make their own decision after considering the doctor's opinion, and about 90% reported being sufficiently involved in the treatment discussion. Men preferring AS had slightly more uncertainty about their decisions than those preferring AT. CONCLUSIONS Subjects were actively engaged in decision making and considered a range of treatments. However, we found knowledge gaps about treatment complications among those preferring AT and slightly more decisional uncertainty among those preferring AS, suggesting the need for early decision support.
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Affiliation(s)
- Richard M Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | | | - Kimberly M Davis
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Tania Lobo
- Department of Biostatistics, Bioinformatics, and Biomathematics, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Jun Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - David Aaronson
- Department of Urology, Kaiser Permanente East Bay, Oakland, CA, USA
| | - David F Penson
- Department of Urological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Kathryn L Taylor
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
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