Extent and Predictors of Decision Regret about Health Care Decisions: A Systematic Review

Case Study Analysis of a Decision Coaching Intervention for Young Adults with Early Psychosis

Young adults with early psychosis often disengage from essential early intervention services (i.e., Coordinated Specialty Care or CSC in the United States). While decision support interventions improve service engagement, their use in this population is underexplored. This study evaluated the feasibility, acceptability, fidelity, and potential impact of a decision coaching intervention for young adults with early psychosis in CSC services. Using a mixed-method, longitudinal, collective case study design, we assessed the intervention's impact on decision-making needs through the Decisional Conflict Scale and qualitative interviews. We also evaluated feasibility, fidelity, and acceptability through observations and feedback from interventionists and participants. Eight young adults from three CSC programs participated, showing variable engagement, with generally favorable fidelity and acceptability ratings. The Decisional Conflict Scale revealed mixed findings, while four themes from qualitative interviews emerged: Perspective and Information Seeking, Motivation and Prioritization, Empowerment and Confidence, and Critical Thinking and Evaluation. The findings suggest that training CSC providers-including peer specialists and clinicians-to deliver decision coaching with fidelity is feasible, well-received by young adults, and potentially impactful on decision-making. Replication in a larger controlled trial, addressing observed study limitations, is warranted. This trial was registered with ClinicalTrials.gov (Identifier: NCT04532034) on August 28, 2020, as Temple University Protocol Record 261047, Facilitating Engagement in Evidence-Based Treatment for Early Psychosis (https://clinicaltrials.gov/ct2/show/NCT04532034?term=NCT04532034&draw=2&rank=1).

A scoping review of decision regret in non-communicable diseases: The emerging roles of patient-clinician communication, psychological aspects, and medical outcomes

OBJECTIVE

To map the existing literature on decision regret among patients with non-communicable diseases (NCDs) and develop an integrated framework to understand its impact on patient outcomes and healthcare processes.

METHODS

A systematic search of PubMed, Embase, CINAHL, Cochrane Library, Google Scholar, and Scopus databases was conducted until January 2024 using the "Population, Concept, Context" framework. The review identified and analyzed 28 studies published between 2005 and 2023 in North America and Europe.

RESULTS

Decision regret primarily arises from mismatches between expected and actual treatment outcomes and is strongly influenced by patient-clinician communication quality. The need for improved informed consent processes and enhanced communication strategies to mitigate regret emerged as prevalent themes. A hypothetical theoretical path was developed to define the relationship between patient expectations, medical outcomes, and emotional responses.

CONCLUSION

Enhanced communication and personalized treatment plans are crucial for addressing the multifaceted nature of regret in healthcare. Improved patient-clinician communication and informed consent processes can significantly reduce decision regret.

PRACTICE IMPLICATIONS

Healthcare providers should focus on effective communication and education to personalize care strategies and align treatment decisions with patient expectations. This could ultimately reduce decision regret and improve patient outcomes.

Role of patient-provider communication on older adults' preferences for continuing colorectal cancer testing and visit satisfaction

OBJECTIVE

To identify possible predictors of older adults' preferences for stopping or continuing colorectal cancer (CRC) testing and satisfaction with medical visits.

METHODS

Cross-sectional, secondary analysis of patient data. The parent study was a two-arm, multi-site clustered randomized trial, assigning primary care physicians to receive shared decision making training plus a reminder, or reminders alone for patients who were due for CRC testing. For the current analysis, patient data were pooled and analyzed without regard to study arm. Patients were aged 76-85 years.

RESULTS

In total, 375 patients reported their preference: 74 % preferred continued testing while 26 % preferred no further testing. In multivariable models, patients were more likely to prefer CRC testing if they had more maximizing preferences for health care, higher anticipated regret at missing a diagnosis, and lower anticipated regret about colonoscopy complications. Patients were more likely to report being extremely satisfied with the visit with longer duration spent discussing testing options.

CONCLUSION

Anticipated decision regret and medical maximizing were associated with preferences for CRC testing. Time spent discussing CRC testing was associated with visit satisfaction.

PRACTICE IMPLICATIONS

To support informed decision making, older adults should be given thorough information about CRC testing, treatments, and post-treatment follow up.

Decision regret and satisfaction with shared decision-making in pancreatic surgery

BACKGROUND

Pancreatic surgery often does not provide long-term survival in patients with cancer or consistently improve symptoms in benign disease. This study aimed to assess decision regret and satisfaction with the decision-making process among patients who underwent pancreatectomy.

METHODS

This study administered the Brehaut Decision Regret Scale (DRS), 9-Item Shared Decision-Making Questionnaire (SDM-Q-9), and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) to all patients who underwent elective pancreatectomies from 2021 to 2023. Decision regret was defined as a DRS of >25. In addition, this study evaluated SDM-Q-9 responses in patients with and without regret.

RESULTS

A total of 143 patients were included in this study, of whom 71 patients (49.6%) completed the distributed surveys. Demographics, pathology, and major complication rates were similar between responders and nonresponders. The indications for surgery were malignancy (67.6%) and benign disease (32.4%). Decision regret after pancreatic surgery was reported in 18.3% of patients. Patients who experienced regret were younger (50.8 ± 18.7 years [younger group] vs 62.0 ± 14.9 years [older group]; P = .03), more likely to have benign disease (39.1% [benign disease] vs 8.3% [malignant disease]; P < .01), underwent a distal pancreatectomy (34.5% [distal pancreatectomy] vs 7.7% [pancreaticoduodenectomy]; P = .02), or experienced a major complication (36.8% [major complication] vs 11.5% [no major complication]; P = .03). Patients with regret had lower global health (57.1 ± 20.1 [patients with regret] vs 76.2 ± 22.2 [patients without regret]; P < .01) and social function scores (61.5 ± 31.5 [patients with regret] vs 77.6 ± 22.0 [patients without regret]; P = .03) on the EORTC QLQ-C30. Patients with regret were less satisfied with the shared decision-making process.

CONCLUSION

Strong decision regret was reported in 18% of patients who underwent pancreatectomy. Younger age, distal pancreatectomy, benign indications, and major postoperative complications were associated with regret. Data from the SDM-9 highlight areas for potential improvement to help patients make decisions aligned with their goals of care.

An online driving decision aid for older drivers reduces ambivalence and regret about driving decisions: Randomized trial

BACKGROUND

Decisions about driving cessation can be stressful for older adults. We tested effects of a driving decision aid (DDA) on psychosocial outcomes among older drivers during two-year follow-up.

METHODS

Multisite randomized controlled trial of licensed drivers ages ≥70 with at least one diagnosis associated with increased likelihood of driving cessation, without significant cognitive impairment. The intervention was the online Healthwise® DDA, addressing "Is it time to stop driving?"; controls received National Institute on Aging web-based information for older drivers. Outcomes were assessed at baseline, 6, 12, 18, and 24 months. Primary outcomes were the Decision Regret Scale, Decisional Conflict Scale (assessing decisional ambivalence or uncertainty), and PROMIS Depression (4a) Scale. Self-reported Life-Space Assessment (assessing community mobility), crashes and driving outcomes were also assessed. Using intention-to-treat analyses, we tested whether DDA (vs. control) effects on each outcome differed during follow-up using a study group by time interaction. Longitudinal outcomes were modeled using generalized linear mixed models, accounting for repeated measures, age, site, and baseline visit before vs. during COVID.

RESULTS

We enrolled 301 participants (age at enrollment: mean 77.1 (range 70-92) years; 51% identifying as female). During follow-up, the DDA group had less decisional conflict (pinteraction = 0.010) and decision regret (pinteraction = 0.012). The DDA had its greatest effect on decisional conflict immediately post-intervention (adjusted mean ratio [aMR] = 0.87; 95%CI: 0.79, 0.97) and on decision regret at 12-month follow-up (aMR = 0.45; 95%CI: 0.27, 0.72). Odds of depression were similar between groups during follow-up (pinteraction = 0.237). The intervention did not negatively affect life space, crashes, or other driving outcomes.

CONCLUSIONS

In older drivers, the Healthwise® DDA reduced uncertainty and regret about driving decisions during longitudinal follow-up, without adversely affecting community mobility or crash risk. Use of DDAs in clinical and other settings may reduce the distress older adults often experience when making decisions about driving cessation.

Caregiver decisional regret following reconstructive bladder surgery in children with neurogenic bladder

BACKGROUND

Surgical management for neurogenic bladder requires complex decision-making by physicians, patients, and caregivers. Assessing decisional regret (DR) as a patient-reported outcome among caregivers could inform future counseling and shared decision-making.

OBJECTIVE

To assess DR among caregivers of children with neurogenic bladder following reconstructive bladder surgery.

STUDY DESIGN

A questionnaire including a validated DR survey was distributed to English-speaking caregivers of children with neurogenic bladder who had undergone reconstructive bladder surgery at Children's Hospital Colorado. DR scores range from zero to 100, with higher numbers indicating higher regret. Wilcoxon rank sum test and Spearman correlation were performed to assess differences in DR scores by patient demographic factors or disease factors.

RESULTS

Forty-five of 210 English-speaking caregivers completed the DR survey. The median DR score was 5, with 40% of subjects reporting with a DR score of zero and 24% of subjects with a DR score of 30 or higher. Patient sex and Mitrofanoff leakage were found to be associated with DR, with caregivers of male patients reporting significantly higher DR. Surgical procedure did not have a statistically significant impact on DR scores.

DISCUSSION

Sparse existing data exploring DR among patients with neurogenic bladder suggest DR following reconstructive bladder surgery is low, with few identifiable predictors of regret. While the majority of caregivers in our study report little or no DR, one quarter of caregivers report moderate to high DR. The limitations of this study include small cohort size, low response rate, exclusion of non-English speaking patients, and the potential for recall bias due to the survey design of the study.

CONCLUSION

Caregiver DR following bladder reconstruction in children with neurogenic bladder is generally low, however a subset of caregivers reports significant DR. This study suggests that caregivers of male children may have higher DR, a finding that merits further investigation.

Predicting patient reported outcome measures: a scoping review for the artificial intelligence-guided patient preference predictor

Background

The algorithmic patient preference predictor (PPP) has been proposed to aid in decision making for incapacitated patients in the absence of advanced directives. Ethical and legal challenges aside, multiple practical barriers exist for building a personalized PPP. Here, we examine previous work using machine learning to predict patient reported outcome measures (PROMs) for capacitated patients undergoing diverse procedures, therapies, and life events. Demonstrating robust performance in predicting PROMs for capacitated patients could suggest opportunities for developing a model tailored to incapacitated ones.

Methods

We performed a scoping review of PubMed, Embase, and Scopus using the PRISMA-ScR guidelines to capture studies using machine learning to predict PROMs following a medical event alongside qualitative studies exploring a theoretical PPP.

Results

Sixty-eight studies used machine learning to evaluate PROMs; an additional 20 studies focused on a theoretical PPP. For PROMs, orthopedic surgeries (n = 33) and spinal surgeries (n = 12) were the most common medical event. Studies used demographic (n = 30), pre-event PROMs (n = 52), comorbidities (n = 29), social determinants of health (n = 30), and intraoperative variables (n = 124) as predictors. Thirty-four different PROMs were used as the target outcome. Evaluation metrics varied by task, but performance was overall poor to moderate for the best reported scores. In models that used feature importance, pre-event PROMs were the most predictive of post-event PROMs. Fairness assessments were rare (n = 6). These findings reinforce the necessity of the integrating patient values and preferences, beyond demographic factors, to improve the development of personalized PPP models for incapacitated patients.

Conclusion

The primary objective of a PPP is to estimate patient-reported quality of life following an intervention. Use of machine learning to predict PROMs for capacitated patients introduces challenges and opportunities for building a personalized PPP for incapacitated patients without advanced directives.

Frailty and decisional regret after elective noncardiac surgery: a multicentre prospective cohort study

BACKGROUND

Frailty is associated with morbidity and mortality after surgery. The association of frailty with decisional regret is poorly defined. Our objective was to estimate the association of preoperative frailty with decisional regret status in the year after surgery.

METHODS

We conducted a secondary analysis of a prospective, multicentre cohort study of patients aged ≥65 years who underwent elective noncardiac surgery. Decisional regret about having undergone surgery was ascertained at 30, 90, and 365 (primary time point) days after surgery using a 3-point ordinal scale. Bayesian ordinal logistic regression was used to estimate the association of frailty with decisional regret, adjusted for surgery type, age, sex, and mental health conditions. Subgroup and sensitivity analyses were conducted.

RESULTS

We identified 669 patients; 293 (43.8%) lived with frailty. At 365 days after surgery, the unadjusted odds ratio (OR) associating frailty with greater decisional regret was 2.21 (95% credible interval [CrI] 0.98-5.09; P(OR>1)=0.97), which was attenuated after confounder adjustment (adjusted OR 1.68, 95% CrI 0.84-3.36; P(OR>1)=0.93). Similar results were estimated at 30 and 90 days. Additional adjustment for baseline comorbidities and disability score substantially altered the OR at 365 days (0.89, 95% CrI 0.37-2.12; P(OR>1)=0.39). There was a high probability that surgery type was an effect modifier (non-orthopaedic: OR 1.90, 95% CrI 1.00-3.59; P(OR>1)=0.98); orthopaedic: OR 0.87, 95% CrI 0.41-1.91; P(OR>1)=0.36).

CONCLUSIONS

Among older surgical patients, there appears to be a complex association with frailty and decisional regret, with substantial heterogeneity based on assumed causal pathways and surgery type. Future studies are required to untangle the complex interplay between these factors.

Patient-related decisional regret: An evolutionary concept analysis

BACKGROUND

Health-related decision-making is a complex process given the variability of treatment options, conflicting treatment plans, time constraints and variable outcomes. This complexity may result in patients experiencing decisional regret following decision-making. Nonetheless, literature on decisional regret in the healthcare context indicates inconsistent characterization and operationalization of this concept.

AIM(S)

To conceptually define the phenomenon of decisional regret and synthesize the state of science on patients' experiences with decisional regret.

DESIGN

A concept analysis.

METHODS

Rodgers' evolutionary method guided the conceptualization of this review. An interdisciplinary literature search was conducted from 2003 until 2023 using five databases, PubMed, CINAHL, Embase, PsycINFO and Web of Science. The search informed how the concept manifested across health-related literature. We used PRISMA-ScR checklist to guide the reporting of this review.

RESULTS

Based on the analysis of 25 included articles, a conceptual definition of decisional regret was proposed. Three defining attributes underscored the negative cognitive-emotional nature of this concept, post-decisional experience relating to the decision-making process, treatment option and/or treatment outcome and an immediate or delayed occurrence. Antecedents preceding decisional regret comprised initial psychological or emotional status, sociodemographic determinants, impaired decision-making process, role regret, conflicting treatment plans and adverse treatment outcomes. Consequences of this concept included positive and negative outcomes influencing quality of life, health expectations, patient-provider relationship and healthcare experience appraisal. A conceptual model was developed to summarize the concept's characteristics.

CONCLUSION

The current knowledge on decisional regret is expected to evolve with further exploration of this concept, particularly for the temporal dimension of regret experience. This review identified research, clinical and policy gaps informing our nursing recommendations for the concept's evolution.

NO PATIENT OR PUBLIC CONTRIBUTION

This concept analysis examines existing literature and does not require patient-related data collection. The methodological approach does not necessitate collaboration with the public.

Patient-reported outcomes after oral cancer reconstructions with radial and ulnar forearm-free flaps

OBJECTIVES

This study aimed to evaluate patient-reported quality of life and incidence of decision regret in patients undergoing radial (RFFF) and ulnar forearm-free flaps (UFFF) reconstruction.

MATERIALS AND METHODS

Patients undergoing either RFFF or UFFF were assessed with the University of Washington Quality of Life (UW-QOL) and Oral Health Impact Profile (OHIP-14) questionnaires, and the Decision Regret Scale (DRS), both before and at least 12 months post-reconstruction.

RESULTS

In total, 40 RFFF and 40 UFFF were included. Harvesting time was longer in RFFF (p = 0.043), and the donor-site defect was significantly larger in RFFF than in UFFF (p = 0.044). Patients with UFFF scored better UW-QOL in the appearance, pain, activity, mood, and social functioning domains (p < 0.05). However, the RFFF group excelled in swallowing and chewing domains. The DRS score revealed a significant difference between RFFF and UFFF, with scores of 36.26 versus 27.36, respectively. Moreover, the mean DRS score reduced at 12 months compared with 6 months, significantly superior for UFFF.

CONCLUSION

Oral cancer patients reconstructed with UFFF exhibited a better appearance, social domain, and mild decision regret compared with RFFF, indicating that the UFFF may contribute to improving postoperative quality of life in oral cancer patients.

Decision Regret in Patients with Appendiceal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Decision regret is an emerging patient reported outcome. The aim of this study was to assess the incidence of regret in patients with appendiceal cancer (AC) who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

PATIENTS AND METHODS

An anonymous survey was distributed to patients through the Appendix Cancer and Pseudomyxoma Peritonei (ACPMP) Research Foundation. The Decision Regret Scale (DRS) was employed, with DRS > 25 signifying regret. Patient demographics, tumor characteristics, postoperative outcomes, symptoms (FACT-C), and PROMIS-29 quality of life (QoL) scores were compared between patients who regretted or did not regret (NO-REG) the procedure.

RESULTS

A total of 122 patients were analyzed. The vast majority had no regret about undergoing CRS-HIPEC (85.2%); 18 patients expressed regret (14.8%). Patients with higher regret had: income ≤ $74,062 (72.2% vs 44.2% NO-REG; p = 0.028), major complications within 30 days of surgery (55.6% vs 15.4% NO-REG; p < 0.001), > 30 days hospital stay (38.9% vs 4.8% NO-REG; p < 0.001), a new ostomy (27.8% vs 7.7% NO-REG; p = 0.03), >1 CRS-HIPEC procedure (56.3% vs 12.6% NO-REG; p < 0.001). Patients with worse FACT-C scores had more regret (p < 0.001). PROMIS-29 QOL scores were universally worse in patients with regret. Multivariable analysis demonstrated > 30 days in the hospital, new ostomy and worse gastrointestinal symptom scores were significantly associated with regret.

CONCLUSIONS

The majority of patients with AC undergoing CRS-HIPEC do not regret undergoing the procedure. Lower income, postoperative complications, an ostomy, undergoing > 1 procedure, and with worse long-term gastrointestinal symptoms were associated with increased regret. Targeted perioperative psychological support and symptom management may assist to ameliorate regret.

Associations of Patient and Parent Characteristics With Parental Decision Regret in the PICU: A Secondary Analysis of the 2015-2017 Navigate Randomized Comparative Trial

OBJECTIVES

To identify self-reported meaningful decisions made by parents in the PICU and to determine patient and parent characteristics associated with the development of parental decision regret, a measurable, self-reported outcome associated with psychologic morbidity.

DESIGN

Secondary analysis of the Navigate randomized comparative trial (NCT02333396).

SETTING

Two tertiary, academic PICUs.

PATIENTS

Spanish- or English-speaking parents of PICU patients aged less than 18 years who were expected to remain in the PICU for greater than 24 hours from time of enrollment or who had a risk of mortality greater than 4% based on Pediatric Index of Mortality 2 score.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between April 2015 and March 2017, 233 parents of 209 patients completed a survey 3-5 weeks post-PICU discharge which included the Decision Regret Scale (DRS), a 5-item, 5-point Likert scale tool scored from 0 (no regret) to 100 (maximum regret). Two hundred nine patient/parent dyads were analyzed. The decisions parents reported as most important were categorized as: procedure, respiratory support, medical management, parent-staff interactions and communication, symptom management, fluid/electrolytes/nutrition, and no decision. Fifty-one percent of parents had some decision regret (DRS > 0) with 19% scoring in the moderate-severe range (DRS 26-100). The mean DRS score was 12.7 ( sd 18.1). Multivariable analysis showed that parental Hispanic ethnicity was associated with greater odds ratio (OR 3.12 [95% CI, 1.36-7.13]; p = 0.007) of mild regret. Being parents of a patient with an increased PICU length of stay (LOS) or underlying respiratory disease was associated with greater odds of moderate-severe regret (OR 1.03 [95% CI, 1.009-1.049]; p = 0.004 and OR 2.91 [95% CI, 1.22-6.94]; p = 0.02, respectively).

CONCLUSIONS

Decision regret was experienced by half of PICU parents in the 2015-2017 Navigate study. The characteristics associated with decision regret (parental ethnicity, PICU LOS, and respiratory disease) are easily identifiable. Further study is needed to understand what contributes to regret in this population and what interventions could provide support and minimize the development of regret.

Decision Regret and Decision-Making Process among Caregivers of Older Adults Receiving Home Care: A Cross-Sectional Study

OBJECTIVES

Family caregivers of older adults receiving home care often find themselves in situations in which they must make important and difficult decisions, which can cause conflict and regret. To tailor shared decision making in this context, we aimed to identify the most difficult decisions they faced, assess their levels of decision regret, and explore the associated factors.

DESIGN

This study used a cross-sectional design.

SETTING AND PARTICIPANTS

Participants included 165 caregivers of older adults who received home care services in Korea.

METHODS

We identified difficult decisions perceived by family caregivers of older adults and evaluated decision regret using the Decision Regret Scale (DRS), decisional conflict using the Decisional Conflict Scale (DCS), burden of care using the Short Zarit Burden Inventory, and Preference Control Scale (PCS). We then performed descriptive, bivariate, and multivariate linear regression analyses to identify factors predicting decision regret.

RESULTS

The most frequently reported difficult decisions were related to place of living (71.6%), management of health conditions (15.1%), and end-of-life decisions (13.3%). The mean DCS score was 37.09 (12.67), the DRS score was 32.33 (15.91), and the burden score was 21.81 (8.25). Matching decisions with preferences and aligning decision-making roles significantly reduced regret, while decision conflicts increased regret.

CONCLUSIONS AND IMPLICATIONS

The positive associations between decision regret, decision conflict, and the alignment of decision-making roles highlight the intricate dynamics involved in the decision-making process for family caregivers. These findings emphasize the need for tailored interventions that recognize and address the diverse factors influencing caregivers' decision-making experiences. Future research exploring the efficacy of targeted interventions such as decision-support programs or caregiver education initiatives could offer valuable insights into mitigating decision-related challenges and improving the overall well-being of both caregivers and care recipients.

Shared decision-making, treatment decision regret, and vision-related quality of life among parents of children with myopia: An online survey in Taiwan

OBJECTIVES

To investigate the relationships among myopia treatment, decision regret, shared decision-making, and vision-related quality of life among parents of 6-12-year-old children with myopia.

METHODS

An online Google Forms questionnaire was developed using a cross-sectional design and distributed between January 16 and August 22, 2023. Parents of 6-12-year-old children with myopia were recruited through school nurses working in Taiwan. The children's and parents' demographic data were collected. Study instruments included the Decisional Regret Scale, Shared Decision-Making, and Vision-Related Quality of Life questionnaires. Multivariable linear regression analysis was used to identify factors influencing vision-related quality of life.

RESULTS

Of 350 parents contacted, 314 questionnaires were analyzed. Among the respondents, 77.39 % (n = 243) were mothers, and most were aged >40 years. The mean age of children at myopia diagnosis was 7.12 ± 1.24 years; 46.50 % had < - 1.0 diopters of refractive error. Atropine eye drops were the primary treatment; 17.71 % of children were prescribed orthokeratology for myopia control. Parents reported low levels of decision regret and moderate levels of shared decision-making and vision-related quality of life. Children's age, use of orthokeratology lenses, decision regret, and shared decision-making significantly influenced the vision-related quality of life reported by the parents, accounting for 22.5 % of the variance.

CONCLUSION

The study's findings emphasize the importance of addressing decision regret and promoting shared decision-making in myopia treatment. Eye care professionals should discuss treatment options thoroughly before making decisions. Through shared decision-making, parents can make informed choices about treatments based on a comprehensive understanding of the benefits and drawbacks, ultimately benefitting children's vision health.

Patient perspectives in adverse event reporting after vaginal apical prolapse surgery

BACKGROUND

Many clinical trials use systematic methodology to monitor adverse events and determine grade (severity), expectedness, and relatedness to treatments as determined by clinicians. However, patient perspectives are often not included in this process.

OBJECTIVE

This study aimed to compare clinician vs patient grading of adverse event severity in a urogynecologic surgical trial. Secondary objectives were to estimate the association of patient grading of adverse events with decision-making and quality of life outcomes and to determine if patient perspective changes over time.

STUDY DESIGN

This was a planned supplementary study (Patient Perspectives in Adverse Event Reporting [PPAR]) to a randomized trial comparing 3 surgical approaches to vaginal apical prolapse. In the parent trial, adverse events experienced by patients were collected per a standardized protocol every 6 months during which clinicians graded adverse event severity (mild, moderate, severe/life-threatening). In this substudy, we obtained additional longitudinal patient perspectives for 19 predetermined "PPAR adverse events." Patients provided their own severity grading (mild, moderate, severe/very severe/life-threatening) at initial assessment and at 12 and 36 months postoperatively. Clinicians and patients were masked to each other's reporting. The primary outcome was the interrater agreement (kappa statistic) for adverse event severity between the initial clinician and patient assessment, combining patient grades of mild and moderate. The association between adverse event severity and the Decision Regret Scale, Satisfaction with Decision Scale, the 12-Item Short-Form Health Survey, and Patient Global Impression of Improvement scores was assessed using the Spearman correlation coefficient (ρ) for continuous scales, the Mantel-Haenszel chi-square test for Patient Global Impression of Improvement, and t tests or chi-square tests comparing the assessments of patients who rated their adverse events or symptoms as severe with those who gave other ratings. To describe patient perspective changes over time, the intraobserver agreement was estimated for adverse event severity grade over time using weighted kappa coefficients.

RESULTS

Of the 360 randomly assigned patients, 219 (61%) experienced a total of 527 PPAR adverse events (91% moderate and 9% severe/life-threatening by clinician grading). Mean patient age was 67 years; 87% were White and 12% Hispanic. Among the patients reporting any PPAR event, the most common were urinary tract infection (61%), de novo urgency urinary incontinence (35%), stress urinary incontinence (22%), and fecal incontinence (13%). Overall agreement between clinician and participant grading of severity was poor (kappa=0.24 [95% confidence interval, 0.14-0.34]). Of the 414 adverse events that clinicians graded as moderate, patients graded 120 (29%) as mild and 80 (19%) as severe. Of the 39 adverse events graded as severe by clinicians, patients graded 15 (38%) as mild or moderate. Initial patient grading of the most severe reported adverse event was mildly correlated with worse Decision Regret Scale (ρ=0.2; P=.01), 12-Item Short-Form Health Survey (ρ=-0.24; P<.01), and Patient Global Impression of Improvement (P<.01) scores. There was no association between adverse event severity and Satisfaction with Decision Scale score. Patients with an initial grading of "severe" had more regret, lower quality of life, and poorer global impressions of health than those whose worst severity grade was mild (P<.05). Agreement between the patients' initial severity ratings and their ratings at 12 months (kappa=0.48 [95% confidence interval, 0.39-0.58]) and 36 months (kappa=0.45 [95% confidence interval, 0.37-0.53]) was fair.

CONCLUSION

Clinician and patient perceptions of adverse event severity are discordant. Worse severity from the patient perspective was associated with patient-centered outcomes. Including the patient perspective provides additional information for evaluating surgical procedures.

Parental decision regret after pediatric urologic surgeries compared to decisions of everyday life

INTRODUCTION

Parents are at risk of decision regret (DR) for decisions affecting their children. The Decision Regret Scale (DRS) measures medical DR but lacks context outside of healthcare.

OBJECTIVE

To compare parental DR 1) between common pediatric urologic surgeries and everyday decisions and 2) with preference to make a different choice.

METHODS

We conducted a cross-sectional online survey of randomly selected parents >1year (y) after their children underwent: orchiopexy (males ≤10y), open ureteral reimplant (OUR, females 2-6y), open pyeloplasty (OP, ≤2y), or robotic pyeloplasty (RP, 5-17y) (2017-2021). Higher DRS scores indicate increased DR (none: 0, mild: 1-25, moderate: 30-50, strong: 55-75, very strong: 80-100). Parents completed DRS on four decisions: their child's surgery, most recent/current romantic relationship, most recent leased/purchased car, and most recent purchased meal. Parents reported if they would make the same choice (yes/no). Nonparametric statistics were used.

RESULTS

We surveyed 191 parents (orchiopexy n = 52, OUR n = 50, OP n = 51, RP n = 38). The median parent age was 36y (mothers: 86%). Some DR was reported for all decisions, but with significant differences in DR severity. The lowest median DRS score was seen with surgery (orchiopexy 0 [IQR 0-10], OUR 0 [IQR 0-5], OP 0 [IQR 0-0], RP 0 [IQR 0-0]), with no difference between surgery groups (p = 0.78). This was followed by relationship (0, IQR 0-20), car (15, IQR 0-25), and meal (20, IQR 0-30, p < 0.001). Most parents did not report any DR regarding surgery (orchiopexy 69%, OUR 74%, OP 76%, RP 76%, with no difference between surgery groups p = 0.85, Summary Figure). Comparatively, 59% of parents did not have any regret about their relationship, 37% their car, and 28% their meal (p < 0.001). All surgical DR was mild or moderate. No parent (0%) would have chosen differently for their child's surgery versus 4-12% for non-surgical decisions (p < 0.001). Overall, increasing DR corresponded to increasing desire to have made a different choice (DRS≤10: 0%, DRS 45-50: 32%, DRS 55-60: 66%, DRS≥75: 100%, p < 0.001).

CONCLUSION

Parental DR varied between urological surgical and non-surgical decisions. It was lowest after surgery. Some regret was reported after every decision, but the subset of parents with regret was smallest after surgical decisions. Positive DRS scores do not necessarily correspond to parents wishing they made a different choice.

Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation

Background

There is no consensus on optimal management of pilonidal disease. Surgical practice is varied, and existing literature is mainly single-centre cohort studies of varied disease severity, interventions and outcome assessments.

Objectives

A prospective cohort study to determine: • disease severity and intervention relationship • most valued outcomes and treatment preference by patients • recommendations for policy and future research.

Design

Observational cohort study with nested mixed-methods case study. Discrete choice experiment. Clinician survey. Three-stage Delphi survey for patients and clinicians. Inter-rater reliability of classification system.

Setting

Thirty-one National Health Service trusts.

Participants

Patients aged > 16 years referred for elective surgical treatment of pilonidal disease.

Interventions

Surgery.

Main outcome measures

Pain postoperative days 1 and 7, time to healing and return to normal activities, complications, recurrence. Outcomes compared between major and minor procedures using regression modelling, propensity score-based approaches and augmented inverse probability weighting to account for measured potential confounding features.

Results

Clinician survey: There was significant heterogeneity in surgeon practice preference. Limited training opportunities may impede efforts to improve practice. Cohort study: Over half of patients (60%; N = 667) had a major procedure. For these procedures, pain was greater on day 1 and day 7 (mean difference day 1 pain 1.58 points, 95% confidence interval 1.14 to 2.01 points, n = 536; mean difference day 7 pain 1.53 points, 95% confidence interval 1.12 to 1.95 points, n = 512). There were higher complication rates (adjusted risk difference 17.5%, 95% confidence interval 9.1 to 25.9%, n = 579), lower recurrence (adjusted risk difference -10.1%, 95% confidence interval -18.1 to -2.1%, n = 575), and longer time to healing (>34 days estimated difference) and time to return to normal activities (difference 25.9 days, 95% confidence interval 18.4 to 33.4 days). Mixed-methods analysis: Patient decision-making was influenced by prior experience of disease and anticipated recovery time. The burden involved in wound care and the gap between expected and actual time for recovery were the principal reasons given for decision regret. Discrete choice experiment: The strongest predictors of patient treatment choice were risk of infection/persistence (attribute importance 70%), and shorter recovery time (attribute importance 30%). Patients were willing to trade off these attributes. Those aged over 30 years had a higher risk tolerance (22.35-34.67%) for treatment failure if they could experience rapid recovery. There was no strong evidence that younger patients were willing to accept higher risk of treatment failure in exchange for a faster recovery. Patients were uniform in rejecting excision-and-leave-open because of the protracted nursing care it entailed. Wysocki classification analysis: There was acceptable inter-rater agreement (κ = 0.52, 95% confidence interval 0.42 to 0.61). Consensus exercise: Five research and practice priorities were identified. The top research priority was that a comparative trial should broadly group interventions. The top practice priority was that any interventions should be less disruptive than the disease itself.

Limitations

Incomplete recruitment and follow-up data were an issue, particularly given the multiple interventions. Assumptions were made regarding risk adjustment.

Conclusions and future work

Results suggest the burden of pilonidal surgery is greater than reported previously. This can be mitigated with better selection of intervention according to disease type and patient desired goals. Results indicate a framework for future higher-quality trials that stratify disease and utilise broad groupings of common interventions with development of a patient-centred core outcome set.

Trial registration

This trial is registered as ISRCTN95551898.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/17/02) and is published in full in Health Technology Assessment; Vol. 28, No. 33. See the NIHR Funding and Awards website for further award information.

A Cross-sectional Study of Regret in Cancer Patients After Sharing Test Results for Pathogenic Germline Variants of Hereditary Cancers With Relatives

BACKGROUND

Research on whole genome/exome sequencing is increasing worldwide. However, challenges are emerging in relation to receiving germline pathogenic variant results and sharing them with relatives.

OBJECTIVE

The aim of this study was to investigate the occurrence of and reasoning related to regret among patients with cancer who shared single-gene testing results and whole exome sequencing with family members.

METHODS

This was a single-center, cross-sectional study. The Decision Regret Scale was administered, and descriptive questionnaires were used with 21 patients with cancer.

RESULTS

Eight patients were classified as having no regret, 9 patients were classified as having mild regret, and 4 patients were classified as having moderate to strong regret. Reasons patients felt that sharing was the right decision included the following: to allow relatives and children to take preventive measures, the need for both parties to be aware of and ready for the hereditary transmission of cancer, and the need to be able to discuss the situation with others. On the other hand, some patients did not think it was a good decision to share the information because of the associated anxiety.

CONCLUSIONS

Regret over sharing test results for pathogenic germline variants of hereditary cancers with relatives tended to be low. The main reason was that patients believed that they were able to benefit others by sharing.

IMPLICATIONS FOR PRACTICE

Healthcare professionals need to understand the postsharing perceptions and experiences of patients and support them throughout the sharing process.

Decisional Conflict Regarding Disease-Modifying Treatment Choices Among Patients with Mid-Stage Relapsing-Remitting Multiple Sclerosis

Purpose

Shared decision-making is critical in multiple sclerosis (MS) due to the uncertainty of the disease trajectory over time and the large number of treatment options with differing efficacy, safety and administration characteristics. The aim of this study was to assess patients' decisional conflict regarding the choice of a disease-modifying therapy and its associated factors in patients with mid-stage relapsing-remitting multiple sclerosis (RRMS).

Methods

A multicenter, non-interventional study was conducted. Adult patients with a diagnosis of RRMS (2017 revised McDonald criteria) and disease duration of 3 to 8 years were included. The level of uncertainty experienced by a patient when faced with making a treatment choice was assessed using the 4-item Decisional Conflict Scale. A battery of patient-reported and clinician-rated measures was administered to obtain information on symptom severity, illness perception, illness-related uncertainty, regret, MS knowledge, risk taking behavior, preferred role in the decision-making process, cognition, and self-management. Patients were recruited during routine follow-up visits and completed all questionnaires online using electronic tablets at the hospital. A multivariate logistic regression analysis was conducted.

Results

A total of 201 patients were studied. Mean age (Standard deviation) was 38.7 (8.4) years and 74.1% were female. Median disease duration (Interquartile range) was 6.0 (4.0-7.0) years. Median EDSS score was 1.0 (0-2.0). Sixty-seven (33.3%) patients reported a decisional conflict. These patients had lower MS knowledge and more illness uncertainty, anxiety, depressive symptoms, fatigue, subjective symptom severity, a threatening illness perception, and poorer quality of life than their counterparts. Lack of decisional conflict was associated with MS knowledge (Odds ratio [OR]=1.195, 95% CI 1.045, 1.383, p=0.013), self-management (OR=1.049, 95% CI 1.013, 1.093, p=0.018), and regret after a healthcare decision (OR=0.860, 95% CI 0.756, 0.973, p=0.018) in the multivariate analysis.

Conclusion

Decisional conflict regarding the selection of a disease-modifying therapy was a common phenomenon in patients with mid-stage RRMS. Identifying factors associated with decisional conflict may be useful to implement preventive strategies that help patients better understand their condition and strengthen their self-management resources.

Patient-Reported Decisional Regret After Operative Otolaryngology Procedures: A Scoping Review

OBJECTIVE

To review the published literature on decisional regret in adult patients undergoing operative otolaryngology procedures. The primary outcome was decisional regret scale (DRS) scores. DRS scores of 0 indicate no regret, 1-25 mild regret, and >25 moderate to strong/severe regret.

DATA SOURCES

A comprehensive librarian-designed strategy was used to search MEDLINE, Embase, and CINAHL from inception to September 2023.

REVIEW METHODS

Inclusion criteria consisted of English-language studies of adult patients who underwent operative otolaryngology treatments and reported DRS scores. Data was extracted by two independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were followed. Oxford Centre's Levels of Evidence were used for quality assessment.

RESULTS

In total, 6306 studies were screened by two independent reviewers; 13 studies were included after full-text analysis. Subspecialties comprised: Head and neck (10), endocrine (1), general (1), and rhinology (1). The DRS results of the included studies spanned a mean range of 10.1-23.9 or a median range of 0-20.0. There was a trend toward more decisional regret after large head and neck procedures or when patients underwent multiple treatment modalities. Depression, anxiety, and patient-reported quality of life measures were all correlated with decisional regret. Oxford Centre's Levels of Evidence ranged from 2 to 4.

CONCLUSION

This is the first comprehensive review of decisional regret in otolaryngology. The majority of patients had no or mild (DRS <25) decisional regret after otolaryngology treatments. Future research on pre-operative counseling and shared decision-making to further minimize patient decisional regret is warranted.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2562-2567, 2024.

Assessing the Content and Effect of Web-Based Decision Aids for Postmastectomy Breast Reconstruction: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Web-based decision aids have been shown to have a positive effect when used to improve the quality of decision-making for women facing postmastectomy breast reconstruction (PMBR). However, the existing findings regarding these interventions are still incongruent, and the overall effect is unclear.

OBJECTIVE

We aimed to assess the content of web-based decision aids and its impact on decision-related outcomes (ie, decision conflict, decision regret, informed choice, and knowledge), psychological-related outcomes (ie, satisfaction and anxiety), and surgical decision-making in women facing PMBR.

METHODS

This systematic review and meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 6 databases, PubMed, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science Core Collection, were searched starting at the time of establishment of the databases to May 2023, and an updated search was conducted on April 1, 2024. MeSH (Medical Subject Headings) terms and text words were used. The Cochrane Risk of Bias Tool for randomized controlled trials was used to assess the risk of bias. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

In total, 7 studies included 579 women and were published between 2008 and 2023, and the sample size in each study ranged from 26 to 222. The results showed that web-based decision aids used audio and video to present the pros and cons of PMBR versus no PMBR, implants versus flaps, and immediate versus delayed PMBR and the appearance and feel of the PMBR results and the expected recovery time with photographs of actual patients. Web-based decision aids help improve PMBR knowledge, decisional conflict (mean difference [MD]=-5.43, 95% CI -8.87 to -1.99; P=.002), and satisfaction (standardized MD=0.48, 95% CI 0.00 to 0.95; P=.05) but have no effect on informed choice (MD=-2.80, 95% CI -8.54 to 2.94; P=.34), decision regret (MD=-1.55, 95% CI -6.00 to 2.90 P=.49), or anxiety (standardized MD=0.04, 95% CI -0.50 to 0.58; P=.88). The overall Grading of Recommendations, Assessment, Development, and Evaluation quality of the evidence was low.

CONCLUSIONS

The findings suggest that the web-based decision aids provide a modern, low-cost, and high dissemination rate effective method to promote the improved quality of decision-making in women undergoing PMBR.

TRIAL REGISTRATION

PROSPERO CRD42023450496; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=450496.

Decision Regret Following the Choice of Surgery or Active Surveillance for Small, Low-Risk Papillary Thyroid Cancer: A Prospective Cohort Study

Background: It is important to understand cancer survivors' perceptions about their treatment decisions and quality of life. Methods: We performed a prospective observational cohort study of Canadian patients with small (<2 cm) low-risk papillary thyroid cancer (PTC) who were offered the choice of active surveillance (AS) or surgery (Clinicaltrials.gov NCT03271892). Participants completed a questionnaire one year after their treatment decision. The primary intention-to-treat analysis compared the mean decision regret scale total score between patients who chose AS or surgery. A secondary analysis examined one-year decision regret score according to treatment status. Secondary outcomes included quality of life, mood, fear of disease progression, and body image perception. We adjusted for age, sex, and follow-up duration in linear regression analyses. Results: The overall questionnaire response rate was 95.5% (191/200). The initial treatment choices of respondents were AS 79.1% (151/191) and surgery 20.9% (40/191). The mean age was 53 years (standard deviation [SD] 15 years) and 77% (147/191) were females. In the AS group, 7.3% (11/151) of patients crossed over to definitive treatment (two for disease progression) before the time of questionnaire completion. The mean level of decision regret did not differ significantly between patients who chose AS (mean 22.4, SD 13.9) or surgery (mean 20.9, SD 12.2) in crude (p = 0.730) or adjusted (p = 0.29) analyses. However, the adjusted level of decision regret was significantly higher in patients who initially chose AS and crossed over to surgery (beta coefficient 10.1 [confidence interval; CI 1.3-18.9], p = 0.02), compared with those remaining under AS. In secondary adjusted analyses, respondents who chose surgery reported that symptoms related to their cancer or its treatment interfered with life to a greater extent than those who chose AS (p = 0.02), but there were no significant group differences in the levels of depression, anxiety, fear of disease progression, or overall body image perception. Conclusions: In this study of patients with small, low-risk PTC, the mean level of decision regret pertaining to the initial disease management choice was relatively low after one year and it did not differ significantly for respondents who chose AS or surgery.

Decisional regret following corrective adult spinal deformity surgery: a single institution study of incidence and risk factors

PURPOSE

To assess the characteristics and risk factors for decisional regret following corrective adult spinal deformity (ASD) surgery at our hospital.

METHODS

This is a retrospective cohort study of a single-surgeon ASD database. Adult patients (> 40 years) who underwent ASD surgery from May 2016 to December 2020 with minimum 2-year follow-up were included (posterior-only, ≥ 4 levels fused to the pelvis) (n = 120). Ottawa decision regret questionnaires, a validated and reliable 5-item Likert scale, were sent to patients postoperatively. Regret scores were defined as (1) low regret: 0-39 (2) medium to high regret: 40-100. Risk factors for medium or high decisional regret were identified using multivariate models.

RESULTS

Ninety patients were successfully contacted and 77 patients consented to participate. Nonparticipants were older, had a higher incidence of anxiety, and higher ASA class. There were 7 patients that reported medium or high decisional regret (9%). Ninety percentage of patients believed that surgery was the right decision, 86% believed that surgery was a wise choice, and 87% would do it again. 8% of patients regretted the surgery and 14% believed that surgery did them harm. 88% of patients felt better after surgery. On multivariate analysis, revision fusion surgery was independently associated with an increased risk of medium or high decisional regret (adjusted odds ratio: 6.000, 95% confidence interval: 1.074-33.534, p = 0.041).

CONCLUSIONS

At our institution, we found a 9% incidence of decisional regret. Revision fusion was associated with increased decisional regret. Estimates for decisional regret should be based on single-institution experiences given differences in patient populations.

Post-operative patient perception of decisional regret in cochlear implant recipients

IMPORTANCE

Decision regret post-surgery has has been linked to health outcomes for a number of elective procedures but is understudied in cochlear implantation satisfaction. Theunpredictability in outcomes may lead to unmet expectations by the recipient. This study is the first study to investigate the decision regret concept in cochlear implant recipients.

OBJECTIVE

Tto investigate post-operative decision regret in (CI) recipients.

DESIGN

This was a prospective cohort study using the validated Ottawa Decision Regret Scale, and whether the CI met the patient's expectations. Variables potentially associated with decision regret including patient demographics, post-operative speech perception scores, duration of deafness, duration of CI use and age were analyzed using the logistic regression model.

SETTING

This was a multi-center study. Participants were recruited and enrolled from the University of Miami and the University of Kansas in an outpatient setting.

PARTICIPANTS

Adult, English-speaking CI recipients with at least 6 months of listening experience with their implant.

RESULTS

Out of 173 58% reported no regret, 27% reported mild, and 15% reported moderate-to-strong regret. Expectations were met in 77% while not meeting expectations in 14%. The remaining 8% were neutral. Decisional regret was significantly associated (p = 0.02) with poor post-operative speech perception. No other variables were associated with regret.

CONCLUSIONS

Post-operative decision regret was reported by 42% of CI recipients. Poor speech perception abilities were associated with increased risk of regret. Further research is required to identify regret risks and provide resources to mitigate regret in CI recipients.

Exploring Decisional Conflict Experienced by Individuals Considering Metoidioplasty and Phalloplasty Gender-affirming Surgery

Background

Metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) is increasingly performed and requires patients to make complex decisions that may lead to decisional uncertainty. This study aimed to evaluate decisional conflict in individuals considering MaPGAS.

Methods

We administered a cross-sectional survey to adult participants assigned female sex at birth and considering MaPGAS, recruited via social media platforms and community health centers. We collected data on demographics, medical and surgical history, MaPGAS type considered, and the Decisional Conflict Scale (DCS). DCS scores range from 0 to 100 (>37.5 indicates greater decisional conflict). Demographic characteristics and DCS scores were compared between subgroups, using descriptive and chi-square statistics. Participants commented on MaPGAS uncertainty, and their comments were evaluated and thematically analyzed.

Results

Responses from 264 participants were analyzed: mean age 29 years; 64% (n = 168) trans men, 80% (n = 210) White, 78% (n = 206) nonrural, 45% (n = 120) privately insured, 56% (n = 148) had 4 or more years of college, 23% (n = 84) considering metoidioplasty, 24% (n = 87) considering phalloplasty, and 26% (n = 93) considering metoidioplasty and phalloplasty. DCS total scores were significantly higher (39.8; P < 0.001) among those considering both MaPGAS options, as were mean ratings on the Uncertainty subscale [64.1 (SD 25.5; P < 0.001)]. Concerns surrounding complications were the top factor contributing to uncertainty and decisional conflict.

Conclusions

In a cross-sectional national sample of individuals seeking MaPGAS, decisional uncertainty was the highest for those considering both MaPGAS options compared with metoidioplasty or phalloplasty alone. This suggests this cohort would benefit from focused decision support.

Decisional Conflict and Decision Regret in Head and Neck Oncology: A Systematic Review and Meta-Analysis

Importance

Head and neck cancer (HNC) often requires treatment with a major impact on quality of life. Treatment decision-making is often challenging, as it involves balancing survival against the preservation of quality of life and choosing among treatments with comparable outcomes but variation in morbidity and adverse events; consequently, the potential for decisional conflict (DC) and decision regret (DR) is high.

Objectives

To summarize the literature on DC and DR in HNC, to give an overview of its prevalence and extent, and to advise on clinical practice and future research.

Data Sources

Embase, Web of Science, MEDLINE, and PsycINFO were searched up to February 24, 2023, including all years of publication.

Study Selection

Eligible studies addressed DC and/or DR as primary or secondary outcomes with any instrument in HNC, except cutaneous tumors. Two mutually blinded researchers conducted screening and inclusion with support of an artificial intelligence assistant and conducted risk of bias (ROB) assessment.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed for data extraction. ROB assessments were done using Critical Appraisal Skills Programme (qualitative) and CLARITY (quantitative). Meta-analysis with a random-effects model was used to obtain pooled prevalence estimates for DC and DR when at least 4 sufficiently clinically homogeneous studies were available.

Main Outcomes and Measures

Prevalence of DC (qualitative, Decisional Conflict Scale, SURE questionnaire) and DR (qualitative, study-specific questionnaires, Decision Regret Scale, Shame and Stigma Scale).

Results

Overall, 28 studies were included, with 16 included in meta-analyses for DR prevalence. The pooled prevalence of clinically relevant DR above the cutoff score for validated questionnaires (11 studies; 2053 participants) was 71% (95% CI, 58%-82%; I2 = 94%), while for study-specific questionnaires (5 studies; 674 participants) it was 11% (95% CI, 5%-22%; I2 = 92%). Only 4 studies investigated DC, showing a prevalence of 22.6% to 47.5% above cutoff values. Derived overarching themes found in qualitative studies were preparation, shared decision-making roles, information, time pressure, stress of diagnosis, and consequences.

Conclusions and Relevance

Although limited data on DC and DR were available, the studies performed indicated that DC and DR are highly prevalent issues in HNC. Results suggest that study-specific questionnaires underestimated DR. The findings underscore the rationale to improve counseling and shared decision-making for this patient population.

Factors associated with decision regret after bariatric surgery

It is assumed that the individuals who undergo bariatric surgery will experience significant improvements in their health and overall well-being. However, it is yet to be examined whether these individuals may also experience subsequent decision regret. The level of regret regarding the choice to undergo bariatric surgery was assessed 1 year after bariatric surgery using the Decision Regret Scale (DRS). Associations of regret with patient characteristics, complications, weight loss and quality of life (BODY-Q) were investigated using linear regression analyses. In total, 115 patients completed the DRS (92% underwent Roux-en-Y gastric bypass Roux-en-Y gastric bypass and 8% underwent sleeve gastrectomy (SG)). Two out of 115 patients indicated absolute regret about their decision to undergo bariatric surgery because of insufficient weight loss and complications. The median decision regret score was zero (range 0-80). Most patients experienced no decision regret (50.4%), followed by mild regret (34.8%) and moderate to strong regret (14.8%). Higher levels of regret were associated with having osteo-articular disorders, gastro-oesophageal reflux disease or a history of psychiatric disorders at baseline. Patients with mild regret demonstrated significantly more weight loss and better psychological function. Major surgical complications were not associated with increased decision regret. Only two out of 115 patients (1.7%) indicated absolute regret about their decision to undergo bariatric surgery, and 15% reported moderate-to-strong regret according to the results of the DRS. These findings should be considered when providing pre-operative counselling and could assist patients in their decision-making process.

Decision regret, and other mental health outcomes, following fertility preservation in the transgender individual compared to the cisgender woman

PURPOSE

This study aimed to (1) determine differences in depression, anxiety, body image, quality-of-life (QOL), and decision regret scale (DRS) scores in transgender individuals undergoing fertility preservation (FP) compared to those who decline and (2) determine if DRS score following FP varies between transgender individuals and cisgender women.

METHODS

Sixteen transgender birth-assigned (BA) females and 13 BA males, undergoing FP consultation at an academic center between January 2016 and November 2019, were compared to each other and cisgender cohorts with pre-existing data: 201 women undergoing elective oocyte cryopreservation (EOC) between 2012 and 2016 and 44 women with cancer undergoing FP between 1993 and 2007. Outcomes included demographics; validated scales for depression, anxiety, body image, QOL (see below) in the trans cohort; DRS score in all three cohorts.

RESULTS

Of 29 transgender individuals participating, 10 BA females (62%) and 12 BA males (92%) underwent FP. Beck Depression Inventory II, Hospital Anxiety and Depression Scale, Body Image Scale for Transsexuals, Satisfaction with Life Scale, Short Form Health Survey-36, and DRS scores were not significantly different between trans individuals who underwent FP and those who declined. On univariate modeling, regret was significantly lower in transpeople undergoing FP compared to those who did not (OR 0.118, p = 0.03). BA female and BA male transpatients undergoing FP reported DRS median scores 5 (mean 9) and 7.5 (mean 15), respectively, both were not significantly different from cisgender women (p = 0.97, p = 0.25) nor from each other (p = 0.43).

CONCLUSIONS

Depression, anxiety, body image, and QOL, in a group of individuals presenting for FP consultation, appear similar between transpeople undergoing FP and not, while regret is significantly lower in those choosing FP. FP is an option for transgender individuals without significant differences in regret compared to cisgender women.

Decision regret of cancer patients after radiotherapy: results from a cross-sectional observational study at a large tertiary cancer center in Germany

PURPOSE

The decision-making process regarding cancer treatment is emotionally challenging for patients and families, harboring the risk of decision regret. We aimed to explore prevalence and determinants of decision regret following radiotherapy.

METHODS

This cross-sectional observational study was conducted at a tertiary cancer center to assess decision regret following radiotherapy. The study employed the German version of the Ottawa Decision Regret Scale (DRS) which was validated in the study population. Decision regret was categorized as absent (0 points), mild (1-25 points), and strong (> 25 points). Various psychosocial outcome measures were collected using validated questionnaires to identify factors that may be associated with decision regret.

RESULTS

Out of 320 eligible patients, 212 participated, with 207 completing the DRS. Median age at start of radiotherapy was 64 years [interquartile range (IQR), 56-72], genders were balanced (105 female, 102 male), and the most common cancer types were breast (n = 84; 41%), prostate (n = 57; 28%), and head-and-neck cancer (n = 19; 9%). Radiotherapy was applied with curative intention in 188 patients (91%). Median time between last radiotherapy fraction and questionnaire completion was 23 months (IQR, 1-38). DRS comprehensibility was rated as good or very good by 98% (196 of 201) of patients. Decision regret was reported by 43% (n = 90) as absent, 38% (n = 78) as mild, and 18% (n = 38) as strong. In the multiple regression analysis, poor Eastern Cooperative Oncology Group performance status, low social support, and dissatisfaction with care were independent risk factors for higher decision regret after radiotherapy.

CONCLUSIONS

The German version of the DRS could be used to assess decision regret in a diverse cohort of cancer patients undergoing radiotherapy. Decision regret was prevalent in a considerable proportion of patients. Further studies are necessary to validate these findings and obtain causal factors associated with decision regret after radiotherapy.

A Decision Aid to Support Tubal Sterilization Decision-Making Among Pregnant Women: The MyDecision/MiDecisión Randomized Clinical Trial

Importance

Tubal sterilization is common, especially among individuals with low income. There is substantial misunderstanding about sterilization among those who have undergone the procedure, suggesting suboptimal decision-making about a method that permanently ends reproductive capacity.

Objective

To test the efficacy of a web-based decision aid for improving tubal sterilization decision quality.

Design, Setting, and Participants

This randomized clinical trial conducted between March 2020 and November 2023 included English- or Spanish-speaking pregnant cisgender women aged 21 to 45 years who had Medicaid insurance and were contemplating tubal sterilization after delivery. Participants were recruited from outpatient obstetric clinics in 3 US cities.

Intervention

Participants were randomized 1:1 to usual care (control arm) or to usual care plus a web-based decision aid (MyDecision/MiDecisión) (intervention arm). The aid includes written, audio, and video information about tubal sterilization procedures; an interactive table comparing contraceptive options; values-clarifying exercises; knowledge checks; and a summary report.

Main Outcomes and Measures

The co-primary outcomes were tubal sterilization knowledge and decisional conflict regarding the contraceptive decision. Knowledge was measured as the percentage of correct responses to 10 true-false items. Decisional conflict was measured using the low-literacy Decision Conflict Scale, with lower scores on a range from 0 to 100 indicating less conflict.

Results

Among the 350 participants, mean (SD) age was 29.7 (5.1) years. Compared with the usual care group, participants randomized to the decision aid had significantly higher tubal sterilization knowledge (mean [SD] proportion of questions answered correctly, 76.5% [16.9%] vs 55.6% [22.6%]; P < .001) and lower decisional conflict scores (mean [SD], 12.7 [16.6] vs 18.7 [20.8] points; P = .002). The greatest knowledge differences between the 2 groups were for items about permanence, with more participants in the intervention arm answering correctly that tubal sterilization is not easily reversible (90.1% vs 39.3%; odds ratio [OR], 14.2 [95% CI, 7.9-25.4]; P < .001) and that the tubes do not spontaneously "come untied" (86.6% vs 33.7%; OR, 13.0 [95% CI, 7.6-22.4]; P < .001).

Conclusions and Relevance

MyDecision/MiDecisión significantly improved tubal sterilization decision-making quality compared with usual care only. This scalable decision aid can be implemented into clinical practice to supplement practitioner counseling. These results are particularly important given the recent increase in demand for permanent contraception after the US Supreme Court decision overturning federal abortion protections.

Trial Registration

ClinicalTrials.gov Identifier: NCT04097717.

Factors Associated With Family Surrogate Decisional-Regret Trajectories

CONTEXT/OBJECTIVES

The scarce research on factors associated with surrogate decisional regret overlooks longitudinal, heterogenous decisional-regret experiences and fractionally examines factors from the three decision-process framework stages: decision antecedents, decision-making process, and decision outcomes. This study aimed to fill these knowledge gaps by focusing on factors modifiable by high-quality end-of-life (EOL) care.

METHODS

This observational study used a prior cohort of 377 family surrogates of terminal-cancer patients to examine factors associated with their membership in the four preidentified distinct decisional-regret trajectories: resilient, delayed-recovery, late-emerging, and increasing-prolonged trajectories from EOL-care decision making through the first two bereavement years by multinomial logistic regression modeling using the resilient trajectory as reference.

RESULTS

Decision antecedent factors: Financial sufficiency and heavier caregiving burden increased odds for the delayed-recovery trajectory. Spousal loss, higher perceived social support during an EOL-care decision, and more postloss depressive symptoms increased odds for the late-emerging trajectory. More pre- and postloss depressive symptoms increased odds for the increasing-prolonged trajectory. Decision-making process factors: Making an anticancer treatment decision and higher decision conflict increased odds for the delayed-recovery and increasing-prolonged trajectories. Making a life-sustaining-treatment decision increased membership in the three more profound trajectories. Decision outcome factors: Greater surrogate appraisal of quality of dying and death lowered odds for the three more profound trajectories. Patient receipt of anticancer or life-sustaining treatments increased odds for the late-emerging trajectory.

CONCLUSION

Surrogate membership in decisional-regret trajectories was associated with decision antecedent, decision-making process, and decision outcome factors. Effective interventions should target identified modifiable factors to address surrogate decisional regret.

Fertility preservation choices and decisional regret after gender-affirming surgery in transgender men or gender nonbinary persons

Objective

To investigate the prevalence of decisional regret regarding preoperative fertility preservation choices after gender-affirming surgery or removal of reproductive organs.

Design

Cross-sectional.

Setting

University-based pratice.

Patients

A total of 57 survey respondents identifying as transgender men or gender nonbinary with a history of gender-affirming surgery or removal of reproductive organs between 2014 and 2023 with the University of North Carolina Minimally Invasive Gynecology division.

Intervention

Survey or questionnaire.

Main Outcome Measures

The prevalence and severity of decisional regret regarding preoperative fertility preservation choices were measured with the use of the validated decisional regret scale (DRS) (scored 0-100). Secondary outcomes included patient-reported barriers to pursuing reproductive endocrinology and infertility consultation and fertility preservation treatment.

Results

The survey response rate was 50.9% (57/112). "Mild" to "severe" decisional regret was reported by 38.6% (n = 22) of survey respondents, with DRS scores among all respondents ranging from 0-85. Higher median DRS scores were associated with patient-reported inadequacy of preoperative fertility counseling regarding implications of surgery on future fertility or family-building (0 vs. 50) and fertility preservation options (0 vs. 12.5). No desire for future fertility at the time of fertility counseling was the most frequent reason (68.4%) for declining a referral to reproductive endocrinology and infertility for additional fertility preservation discussion.

Conclusions

Decisional regret regarding preoperative fertility preservation choices is experienced among transgender men or gender nonbinary persons after gender-affirming surgery or the removal of reproductive organs. Preoperative, patient-centered fertility counseling and fertility preservation treatments should be provided to reduce the risk of future regret.

Decision-making experiences regarding kidney transplant among older adults in South Korea: A qualitative descriptive study

OBJECTIVES

To explore the decision-making experiences of older patients with end-stage renal disease who chose to undergo kidney transplantation.

METHODS

This was a qualitative descriptive study.Twelve participants aged over 60 years who underwent kidney transplantation were recruited from a kidney transplant clinic in a hospital in South Korea. Individual in-depth interviews were conducted from March to April 2021. The data were analysed using inductive thematic analysis.

RESULTS

Four main themes were identified: 1) hesitation towards complex and risky kidney transplant, 2) internal suffering due to social prejudice and limits, 3) taking a step back from the decision-making process, and 4) being rushed into a decision on the brink of death.

CONCLUSION

Older patients with end-stage renal disease experience hesitation and difficulties and are passive in the decision-making process for a kidney transplant. They lacked sufficient relevant information and decided to receive transplant surgery, feeling pressured by the recommendations of family and healthcare providers.

PRACTICE IMPLICATIONS

Healthcare professionals should help older patients with end-stage renal disease make proactive decisions by providing tailored education programs and improving communication between the patients and their family members. Changing negative social perceptions and implementing supportive policies are necessary to resolve the difficulties experienced by such patients.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in the data collection as interview participants in this study.

Personal legacy and treatment choices for serious illness: a scoping review

BACKGROUND

Legacy-how one hopes to be remembered after death-is an unexplored and important dimension of decision-making for people facing serious illness.

OBJECTIVES

We conducted a scoping review to answer the following research questions: (1) How do people making treatment choices conceive of legacy? and (2) What treatment choices do people make with legacy in mind?

ELIGIBILITY CRITERIA

Participants included people facing serious illness who discussed how they wanted to be remembered after their own death, or how they hoped to impact others, as they made treatment choices. Studies in English published between 1990 and 2022 were included.

SOURCES OF EVIDENCE

We conducted searches in electronic databases including Medline/PubMed, CINAHL, PsycInfo, SocialWork, AnthropologyPlus, Web of Science, ProQuest and EMBASE databases.

DATA SYNTHESIS

We used an electronic screening tool to screen abstracts and review full-text articles suitable for inclusion. We analysed included articles using Atlas.ti. We constructed tables and narratively synthesised the findings.

RESULTS

We identified three major intersecting legacy goals that influence choices people facing serious illness make about their treatment and health behaviours, and the types of choices people make with legacy in mind. The three legacy goals are: remembrance of the individual self, remembrance of the social self and impact on others' well-being.

CONCLUSIONS

We identify the importance of legacy to patient treatment choices. Understanding for whom this construct is important, what types of legacy goals people hold and how those goals impact treatment choices is necessary to provide patient-centred whole-person care to people facing serious illness.

Sex differences in the relationship between post-vaccination adverse reactions, decision regret, and WTP for the booster dose of COVID-19 vaccine in Taizhou, China

This study investigated sex differences in the relationship between post-vaccination adverse reactions, decision regret, and willingness to pay (WTP) for the booster dose of COVID-19 vaccines. This research carried out an online cross-sectional investigation among healthcare workers (HCWs) in Taizhou, China. In total, 1,054 respondents (165 males and 889 females) have received two-dose COVID-19 vaccination. We performed descriptive analysis, chi-square test, and mediation analysis on the exported data. In this study, 67 (40.6%) males and 429 (48.3%) females had WTP for the booster dose. Our study presented that decision regret mediated the effect of adverse reactions after vaccination on WTP for the booster dose in both male and female groups. In males, decision regret played a completely mediating role, while in females, it acted as a partial mediator. Sex differences in the relationship between post-vaccination side effects, decision regret, and WTP for the third dose were demonstrated in a sample of healthcare workers.

Supporting effective shared decision-making in surgical context: Why framing of choices matters for high-risk patients and clinicians

AIM

In the context of high-risk surgery, shared decision-making (SDM) is important. However, the effectiveness of SDM can be hindered by misalignment between patients and clinicians in their expectations of postoperative outcomes. This study investigated the extent and the effects of this misalignment, as well as its amenability to interventions that encourage perspective-taking.

METHOD

Lay participants with a Charlson Comorbidity Index of ≥4 (representing patients) and surgeons and anaesthetists (representing doctors) were recruited. During an online experiment, subjects in both groups forecast their expectations regarding short-term (0, 1 and 3 months after treatment) and long-term (6, 9 and 12 months after treatment) outcomes of different treatment options for one of three hypothetical clinical scenarios - ischaemic heart disease, colorectal cancer or osteoarthritis of the hip - and then chose between surgical or non-surgical treatment. Subjects in both groups were asked to consider the scenarios from their own perspective (Estimation task), and then to adopt the perspective of subjects in the other study group (Perspective task). The decisions of all participants (surgery vs. non-surgical alternative) were analysed using binomial generalized linear mixed models.

RESULTS

In total, 55 lay participants and 54 doctors completed the online experiment. Systematic misalignment in expectations between high-risk patients and doctors was observed, with patients expecting better surgical outcomes than clinicians. Patients forecast a significantly higher likelihood of engaging in normal activities in the long term (β = -1.09, standard error [SE] = 0.20, t = -5.38, p < 0.001), a lower likelihood of experiencing complications in the long term (β = 0.92, SE = 0.21, t = 4.45, p < 0.001) and a lower likelihood of experiencing depression in both the short term and the long term (β = 1.01, SE = 0.19, t = 5.38, p < 0.001), than did doctors. Compared with doctors, patients forecast higher estimates of experiencing complications in the short term when a non-surgical alternative was selected (β = -0.91, SE = 0.26, t = -3.50, p = 0.003). Despite this misalignment, in both groups surgical treatment was strongly preferred (estimation task: 88.7% of doctors and 80% of patients; perspective task: 82.2% of doctors and 90.1% of patients).

CONCLUSION

When high-risk surgery is discussed, a non-surgical option may be viewed as 'doing nothing', hence reducing the sense of agency and control. This biases the decision-making process, regardless of the expectations that doctors and patients might have about the outcomes of surgery. Therefore, to improve SDM and to increase the agency and control of patients regarding decisions about their care, we advocate framing the non-surgical treatment options in a way that emphasizes action, agency and change.

Pro: Can we influence postoperative outcomes of frail patients after cardiac surgery?

A significant proportion of cardiac surgery patients are frail. The first step to improve outcomes is recognizing that despite reduced postoperative mortality in cardiac surgery, postoperative morbidity remains high, most likely due to more frail patients undergoing surgeries. Moving from a traditional to a patient-oriented outcome paradigm could improve decision-making and help achieve treatment goals relevant to frail patients, such as quicker recovery, symptom control, and strategies to reduce postoperative complications. Frailty recognition can prompt preoperative and postoperative interventions. Exercise programs and nutrition optimization support frail patients in the perioperative period and positively alter outcomes.

Spouses Speak Up: The Impact of Mesh Sling Complications on the Patient's Spouse-A Qualitative Analysis Study

OBJECTIVE

To examine the perspectives, attitudes, and beliefs of the spouses of women with complications of mesh midurethral sling (MUS) surgery with the goal of increasing our understanding of the multidimensional nature of MUS surgery complications.

METHODS

After IRB approval, the spouses of patients who underwent surgery for MUS complications at a single tertiary care institution participated in qualitative interviews. Using an interview guide with standardized prompts, semistructured interviews were conducted. Interviews were transcribed verbatim and reviewed line-by-line by two researchers independently. Inductive content analysis was used to code the transcripts and identify themes, and consensus was achieved by the research team.

RESULTS

Seven male spouses participated in qualitative interviews, and several themes and subthemes were identified. First, spouses expressed feelings of regret. They described that their partner's dyspareunia detracted from their intimate relationship. The participants also reported the negative impact on their lives and their households. Due to the personal nature of the issue, couples would avoid involving friends and family, creating a sense of isolation. Finally, they expressed hope of finding a healthcare team experienced with mesh complications and invested in their spouse's improvement.

CONCLUSION

Spouses of women who experience MUS complications serve as caregivers and provide support; they are impacted by adverse outcomes. It is important to acknowledge their role in patients' healthcare experiences and learn from their insights. Our study lays the foundation for future work and ultimately for improving the experiences of patients and their spouses with MUS surgery and potential complications.

Decision regret among couples experiencing infertility: a mixed methods longitudinal cohort study

BACKGROUND

Decisions for how to resolve infertility are complex and may lead to regret. We examined whether couples and individuals who sought a consultation from a reproductive specialist for infertility later expressed decisional regret about their family-building choices and whether regret was associated with parental role, family-building paths, or outcomes.

METHODS

This longitudinal mixed methods study included women and their partners who completed a questionnaire prior to their initial consultation with a reproductive specialist and 6 years later. The six-year questionnaire included the Ottawa Decision Regret Scale referencing "the decisions you made about how to add a child to your family." A score of 25+ indicates moderate-to-severe regret. Additional items invited reflections on family-building decisions, treatments, and costs. A systematic content analysis assessed qualitative themes.

RESULTS

Forty-five couples and 34 individuals participated in the six-year questionnaire (76% retention rate), Half (n = 61) of participants expressed no regret, which was similar by role (median 0 for women and supporting partners, F = .08; p = .77). One in 5 women and 1 in 7 partners expressed moderate-to-severe regret. Women who did not pursue any treatment had significantly higher regret (median 15; F = 5.6, p < 0.01) compared to those who pursued IVF (median 0) or other treatments (median 0). Women who did not add a child to their family had significantly higher regret (median 35; F = 10.1, p < 0.001) than those who added a child through treatment (median 0), through fostering/adoption (median 0), or naturally (median 5). Among partners, regret scores were not associated with family-building paths or outcomes. More than one-quarter of participants wished they had spent less money trying to add a child to their family. Qualitative themes included gratitude for parenthood despite the burdensome process of family-building as well as dissatisfaction or regret about the process. Results should be confirmed in other settings to increase generalizability.

CONCLUSION

This longitudinal study provides new insight into the burden of infertility. For women seeking parenthood, any of the multiple paths to parenthood may prevent future decision regret. Greater psychosocial, financial, and decision support is needed to help patients and their partners navigate family-building with minimal regret.

Decisional Regret in Long-Term Australian Allogeneic Hematopoietic Stem Cell Transplantation Survivors: A Cross-Sectional Survey

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an intensive but effective treatment for malignant and non-malignant diseases. However, long-term survival often comes at a cost, with survivors experiencing chronic morbidity and are at risk of relapse and secondary malignancy. This study aimed to describe decisional regret in a large cohort of Australian long-term allo-HSCT survivors. A cross-sectional survey was conducted with 441 adults in New South Wales, assessing quality of life (QoL), psychological, social, demographic, and clinical variables. Less than 10% of survivors expressed regret, with chronic graft-versus-host disease being the most important clinical factor. Psycho-socioeconomic factors such as depression, lower QoL scores, lower household income, higher treatment burden, and not resuming sex post-HSCT were also associated with regret. Findings highlight the need for valid informed consent and ongoing follow-up and support for allo-HSCT survivors dealing with life post-transplant. Nurses and healthcare professionals play a critical role in addressing decisional regret in these patients.

Decisional regret, symptom burden, and quality of life following transoral robotic surgery for oropharyngeal cancer

BACKGROUND

Transoral robotic surgery (TORS) has equivalent oncologic control to radiotherapy with potential for improved quality of life (QOL) and lower patient-reported decisional regret.

METHODS

Cross-sectional study between 2016 and 2021 of TORS patients with early-stage oropharyngeal squamous cell carcinoma who completed the Decision Regret Scale (DRS), M. D. Anderson Dysphagia Inventory (MDADI), and University of Washington Quality of Life (UW-QOL). The median time from treatment to questionnaire completion was 1.8 years (IQR 1.4-3.3, range 1.0-5.6).

RESULTS

Of 65 patients, 84.6% expressed no or mild decisional regret. Regret was not associated with clinical parameters or adjuvant treatment but was correlated with MDADI (τavg = -0.23, p < 0.001) and UW-QOL (τavg = -0.27, p < 0.001). Worse MDADI was associated with older age and worse UW-QOL was associated with multi-site operation and shorter time to survey.

CONCLUSIONS

Overall, the TORS cohort expressed very limited decisional regret. DRS scores were unaffected by clinicodemographics or additional adjuvant therapies, but decision regret was correlated with worse QOL and worse swallowing.

Hopes, concerns, satisfaction and regret in a precision medicine trial for childhood cancer: a mixed-methods study of parent and patient perspectives

BACKGROUND

Paediatric precision oncology aims to match therapeutic agents to driver gene targets. We investigated whether parents and patients regret participation in precision medicine trials, particularly when their hopes are unfulfilled.

METHODS

Parents and adolescent patients completed questionnaires at trial enrolment (T0) and after receiving results (T1). Parents opted-in to an interview at T1. Bereaved parents completed a questionnaire 6-months post-bereavement (T1B). We analysed quantitative data with R and qualitative data thematically with NVivo, before integrating all data for interpretation.

RESULTS

182 parents and 23 patients completed T0; 108/182 parents and 8/23 patients completed T1; 27/98 bereaved parents completed T1B; and 45/108 parents were interviewed. At enrolment, participants held concurrent hopes that precision medicine would benefit future children and their child. Participants expressed concern regarding wait-times for receipt of results. Most participants found the trial beneficial and not burdensome, including bereaved parents. Participants reported high trial satisfaction (median scores: parents: 93/100; patients: 80/100). Participants expressed few regrets (parent median scores: parents: 10/100; bereaved parents: 15/100; patient regret: 2/8 expressed minimal regret).

CONCLUSIONS

Even when trial outcomes did not match their hopes, parents and patients rarely regretted participating in a childhood cancer precision medicine trial. These data are critical for integrating participants' views into future precision medicine delivery.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

Importance

There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments.

Objective

To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy.

Design, Setting, and Participants

For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020.

Exposure

Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy.

Main Outcomes and Measures

Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders.

Results

A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses.

Conclusions and Relevance

In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

Patient-Reported Outcomes of Omission of Breast Surgery Following Neoadjuvant Systemic Therapy: A Nonrandomized Clinical Trial

Importance

Patients should have an active role in decisions about pursuing or forgoing specific therapies in treatment de-escalation trials.

Objective

To evaluate longitudinal patient-reported outcomes (PROs) encompassing decisional comfort and health-related quality of life (HRQOL) among patients who elected to enroll in a clinical trial evaluating radiotherapy alone, without breast surgery, for invasive breast cancers with exceptional response to neoadjuvant systemic therapy (NST).

Design, Setting, and Participants

Prospective, single-group, phase 2 clinical trial at 7 US medical centers. Women aged 40 years or older with invasive cT1-2 N0-1 M0 triple-negative or human epidermal growth factor receptor 2 (ERBB2)-positive breast cancer with no pathologic evidence of residual disease following standard NST enrolled from March 6, 2017, to November 9, 2021. Validated PRO measures were administered at baseline and 6, 12, and 36 months post-radiotherapy. Data were analyzed from January to February 2023.

Interventions

PRO measures included the Decision Regret Scale (DRS), Functional Assessment of Cancer Therapy-Lymphedema (FACT-B+4), and Breast Cancer Treatment Outcomes Scale (BCTOS).

Main Outcomes and Measures

Changes in PRO measure scores and subscores over time.

Results

Among 31 patients, the median (IQR) age was 61 (56-66) years, 26 (84%) were White, and 26 (84%) were non-Hispanic. A total of 15 (48%) had triple-negative disease and 16 (52%) had ERBB2-positive disease. Decisional comfort was high at baseline (median [IQR] DRS score 10 [0-25] on a 0-100 scale, with higher scores indicating higher decisional regret) and significantly increased over time (median [IQR] DRS score at 36 months, 0 [0-20]; P < .001). HRQOL was relatively high at baseline (median [IQR] FACT-B composite score 121 [111-134] on a 0-148 scale, with higher scores indicating higher HRQOL) and significantly increased over time (median [IQR] FACT-B score at 36 months, 128 [116-137]; P = .04). Perceived differences between the affected breast and contralateral breast were minimal at baseline (median [IQR] BCTOS score 1.05 [1.00-1.23] on a 1-4 scale, with higher scores indicating greater differences) and increased significantly over time (median [IQR] BCTOS score at 36 months, 1.36 [1.18-1.64]; P < .001). At 36 months postradiotherapy, the cosmetic subscore was 0.45 points higher than baseline (95% CI, 0.16-0.74; P = .001), whereas function, pain, and edema subscores were not significantly different than baseline.

Conclusions and Relevance

In this nonrandomized phase 2 clinical trial, analysis of PROs demonstrated an overall positive experience for trial participants, with longitudinal improvements in decisional comfort and overall HRQOL over time and minimal lasting adverse effects of therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02945579.

Decision regret following opening wedge high tibial osteotomy: Older age as a risk factor

BACKGROUND

Understanding risk factors that can predict decision regret after surgical procedures can potentially increase the quality of patient decision making and reduce decision regret after opening wedge high tibial osteotomy (OWHTO). The purpose of the present study was to identify the risk factors that predict the likelihood of decision regret after OWHTO.

METHOD

Questionnaires were administered to 98 eligible OWHTO recipients more than one year post-operatively. They answered "Yes" or "No" to the question "Would you go for the same choice (OWHTO) if you had to do it over again?" Univariate and multivariate logistic regression analyses were conducted using the decision regret questionnaire as the dependent variable against patient characteristics and surgery related factors. A receiver operating characteristic curve and area under the curve were constructed and calculated for age at surgery. Cut-off values were determined using the Youden principle and receiver operating characteristic curves.

RESULTS

Among the 98 respondents, 18 (18%) reported regretting their decision. Older age at surgery was the only predictive risk factor for decision regret (P < 0.01). The area under the curve for the model using age to predict failure was 0.722. The cut-off value was 71 years. Patients aged 71 years or more had a 7.841 odds ratio for decision regret (P < 0.01).

CONCLUSIONS

Older age emerged as a predictive risk factor for decision regret after OWHTO. Patients aged 71 years or older had a higher decision regret rate after OWHTO than younger patients and should more carefully weigh the suitability of OWHTO against other options.

Decisional-Regret Trajectories From End-of-Life Decision Making Through Bereavement

CONTEXT

Regret plays a central role in surrogate decision making. Research on decisional regret in family surrogates is scarce and lacks longitudinal studies to illustrate the heterogenous, dynamic evolution of decisional regret.

OBJECTIVES

To identify distinct decisional-regret trajectories from end-of-life (EOL) decision making through the first two bereavement years among surrogates of cancer patients.

METHODS

A prospective, longitudinal, observational study was conducted on a convenience sample of 377 surrogates of terminally ill cancer patients. Decisional regret was measured by the five-item Decision Regret Scale monthly during the patient's last six months and 1, 3, 6, 13, 18, and 24 months post loss. Decisional-regret trajectories were identified using latent-class growth analysis.

RESULTS

Surrogates reported substantially high decisional regret (pre- and postloss mean [SD] as 32.20 [11.47] and 29.90 [12.47], respectively). Four decisional-regret trajectories were identified. The resilient trajectory (prevalence: 25.6%) showed a general low decisional-regret level with mild and transient perturbations around the time of patient death only. Decisional regret for the delayed-recovery trajectory (56.3%) accelerated before the patient's death and decreased slowly throughout bereavement. Surrogates in the late-emerging (10.2%) trajectory reported a low decisional-regret level before loss but their decisional regret increased gradually thereafter. The increasing-prolonged trajectory (6.9%) rapidly increased in decisional-regret levels during EOL decision making, peaked one-month post loss, then declined steadily but without a complete resolution.

CONCLUSION

Surrogates heterogeneously suffered decisional regret from EOL decision making through bereavement as evident by four identified distinct decisional-regret trajectories. Early identification and prevention of increasing/prolonged decisional-regret trajectories is warranted.

Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort

OBJECTIVE

To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days.

SUMMARY BACKGROUND DATA

The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes.

METHODS

We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations.

RESULTS

The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret.

CONCLUSIONS

Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02800785.

Decision regret among women considering planned oocyte cryopreservation: a prospective cohort study

PURPOSE

To (1) prospectively characterize the incidence of decision regret among women considering planned oocyte cryopreservation (planned OC), comparing those who pursued treatment vs those who did not freeze eggs, and (2) to identify baseline predictors for future decision regret.

METHODS

A total of 173 women seen in consultation for planned OC were followed prospectively. Surveys were administered at (1) baseline (< 1 week after initial consultation) and (2) follow-up, 6 months after planned OC among participants who froze eggs or 6 months following consultation in the absence of further communication to pursue treatment. The primary outcome was the incidence of moderate-to-severe decision regret, indicated by a Decision Regret Scale score > 25. We also examined predictors of regret.

RESULTS

The incidence of moderate-to-severe regret over the decision to freeze eggs was 9% compared to 51% over the decision not to pursue treatment. Among women who froze eggs, adequacy of information at baseline to decide about treatment (aOR 0.16, 95% CI 0.03, 0.87) and emphasis on future parenthood (aOR 0.80, 95% CI 0.66, 0.99) were associated with reduced odds of regret. Forty-six percent of women who froze eggs regretted not doing so earlier. Among women who did not freeze eggs, the primary reasons were financial and time constraints, correlating with increased odds of decision regret in an exploratory analysis.

CONCLUSIONS

Among women undergoing planned OC, the incidence of decision regret is low compared to the regret confronting women seen in consultation for planned OC but who do not pursue treatment. Provider counseling is key to offset the regret risk.

Decision Regret among Patients with Early-stage Lung Cancer Undergoing Radiation Therapy or Surgical Resection

AIMS

Clinical equipoise exists regarding early-stage lung cancer treatment among patients as trials comparing stereotactic body radiation therapy (SBRT) and surgical resection are unavailable. Given the potential differences in treatment effectiveness and side-effects, we sought to determine the associations between treatment type, decision regret and depression.

MATERIALS AND METHODS

A multicentre, prospective study of patients with stage IA-IIA non-small cell lung cancer (NSCLC) with planned treatment with SBRT or surgical resection was conducted. Decision regret and depression were measured using the Decision Regret Scale (DRS) and Patient Health Questionnaire-4 (PHQ-4) at 3, 6 and 12 months post-treatment, respectively. Mixed linear regression modelling examined associations between treatment and decision regret adjusting for patient sociodemographics.

RESULTS

Among 211 study participants with early-stage lung cancer, 128 (61%) patients received SBRT and 83 (39%) received surgical resection. The mean age was 73 years (standard deviation = 8); 57% were female; 79% were White non-Hispanic. In the entire cohort at 3 months post-treatment, 72 (34%) and 57 (27%) patients had mild and severe decision regret, respectively. Among patients who received SBRT or surgery, 71% and 46% of patients experienced at least mild decision regret at 3 months, respectively. DRS scores increased at 6 months and decreased slightly at 12 months of follow-up in both groups. Higher DRS scores were associated with SBRT treatment (adjusted mean difference = 4.18, 95% confidence interval 0.82 to 7.54) and depression (adjusted mean difference = 3.49, 95% confidence interval 0.52 to 6.47). Neither patient satisfaction with their provider nor decision-making role concordance was associated with DRS scores.

CONCLUSIONS

Most early-stage lung cancer patients experienced at least mild decision regret, which was associated with SBRT treatment and depression symptoms. Findings suggest patients with early-stage lung cancer may not be receiving optimal treatment decision-making support. Therefore, opportunities for improved patient-clinician communication probably exist.

Navigating the perils and pitfalls throughout the consent process in hematopoietic cell transplantation

Hematopoietic cell transplantation (HCT) is a complex treatment used in malignancies and some non-malignant diseases. The informed consent process for HCT can also be complex due to patient- and process-related barriers. The informed consent process needs to be a dynamic and ongoing process, not simply a checklist. As a result of the realities of HCT, we highlight some potential pitfalls to the informed consent process including uncertainty, sociocultural and communication barriers, and decisional regret. The purpose of this comprehensive review is to highlight unique situations which can result in failure of the informed consent process. We also offer potential solutions to these pitfalls, primarily making the informed consent more patient focused through dynamic and continuous processes to mitigate decisional regret.