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Clarkesmith DE, Pattison HM, Khaing PH, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2017; 4:CD008600. [PMID: 28378924 PMCID: PMC6478129 DOI: 10.1002/14651858.cd008600.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013. OBJECTIVES To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF. SEARCH METHODS We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT. DATA COLLECTION AND ANALYSIS Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence). AUTHORS' CONCLUSIONS This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
| | - Helen M Pattison
- Aston UniversitySchool of Life and Health SciencesAston TriangleBirminghamUKB4 7ET
| | - Phyo H Khaing
- University of BirminghamCollege of Medical and Dental Sciences8 Minnesota DriveGreat SankeyBirminghamCheshireUKWA5 3SY
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
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Zeng-Treitler Q, Gibson B, Hill B, Butler J, Christensen C, Redd D, Shao Y, Bray B. The effect of simulated narratives that leverage EMR data on shared decision-making: a pilot study. BMC Res Notes 2016; 9:359. [PMID: 27448407 PMCID: PMC4957847 DOI: 10.1186/s13104-016-2152-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 07/04/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Shared decision-making can improve patient satisfaction and outcomes. To participate in shared decision-making, patients need information about the potential risks and benefits of treatment options. Our team has developed a novel prototype tool for shared decision-making called hearts like mine (HLM) that leverages EHR data to provide personalized information to patients regarding potential outcomes of different treatments. These potential outcomes are presented through an Icon array and/or simulated narratives for each "person" in the display. In this pilot project we sought to determine whether the inclusion of simulated narratives in the display affects individuals' decision-making. Thirty subjects participated in this block-randomized study in which they used a version of HLM with simulated narratives and a version without (or in the opposite order) to make a hypothetical therapeutic decision. After each decision, participants completed a questionnaire that measured decisional confidence. We used Chi square tests to compare decisions across conditions and Mann-Whitney U tests to examine the effects of narratives on decisional confidence. Finally, we calculated the mean of subjects' post-experiment rating of whether narratives were helpful in their decision-making. RESULTS In this study, there was no effect of simulated narratives on treatment decisions (decision 1: Chi squared = 0, p = 1.0; decision 2: Chi squared = 0.574, p = 0.44) or Decisional confidence (decision 1, w = 105.5, p = 0.78; decision 2, w = 86.5, p = 0.28). Post-experiment, participants reported that narratives helped them to make decisions (mean = 3.3/4). CONCLUSIONS We found that simulated narratives had no measurable effect on decisional confidence or decisions and most participants felt that the narratives were helpful to them in making therapeutic decisions. The use of simulated stories holds promise for promoting shared decision-making while minimizing their potential biasing effect.
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Affiliation(s)
- Qing Zeng-Treitler
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Bryan Gibson
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Brent Hill
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA. .,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA.
| | - Jorie Butler
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Carrie Christensen
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Douglas Redd
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Yijun Shao
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Bruce Bray
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
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Clarkesmith DE, Pattison HM, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2013:CD008600. [PMID: 23736948 DOI: 10.1002/14651858.cd008600.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation who are at moderate-to-high risk of stroke, however anticoagulation control (time in therapeutic range (TTR)) is dependent on many factors. Educational and behavioural interventions may impact on patients' ability to maintain their International Normalised Ratio (INR) control. OBJECTIVES To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (2012, Issue 7 of 12), MEDLINE Ovid (1950 to week 4 July 2012), EMBASE Classic + EMBASE Ovid (1947 to Week 31 2012), PsycINFO Ovid (1806 to 2012 week 5 July) on 8 August 2012 and CINAHL Plus with Full Text EBSCO (to August 2012) on 9 August 2012. We applied no language restrictions. SELECTION CRITERIA The primary outcome analysed was TTR. Secondary outcomes included decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), and anxiety. DATA COLLECTION AND ANALYSIS The two review authors independently extracted data. Where insufficient data were present to conduct a meta-analysis, effect sizes and confidence intervals (CIs) of the included studies were reported. Data were pooled for two outcomes, TTR and decision conflict. MAIN RESULTS Eight trials with a total of 1215 AF patients (number of AF participants included in the individual trials ranging from 14 to 434) were included within the review. Studies included education, decision aids, and self-monitoring plus education.For the primary outcome of TTR, data for the AF participants in two self-monitoring plus education trials were pooled and did not favour self-monitoring plus education or usual care in improving TTR, with a mean difference of 6.31 (95% CI -5.63 to 18.25). For the secondary outcome of decision conflict, data from two decision aid trials favoured usual care over the decision aid in terms of reducing decision conflict, with a mean difference of -0.1 (95% CI -0.2 to -0.02). AUTHORS' CONCLUSIONS This review demonstrated that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK. 2School of Life and Health Sciences,Aston University, Birmingham, UK
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Utility of the Millon Behavioral Medicine Diagnostic to predict medication adherence in patients diagnosed with heart failure. J Clin Psychol Med Settings 2011; 18:1-12. [PMID: 21222020 DOI: 10.1007/s10880-010-9217-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Medication non-adherence is common and a primary reason for poor medical outcomes among individuals with heart failure (HF). This study's aims were to determine whether depression, hostility, and the personality-based Millon Behavioral Medicine Diagnostic (MBMD) Medication Abuse scale were associated with medication adherence (e.g., beta-blockers, ACE inhibitors, diuretics, statins) beyond contributions of demographic, medical, and psychosocial variables in an ethnically-diverse sample of 105 men and women diagnosed with HF. In hierarchical regression, greater MBMD Medication Abuse scale scores were associated with poorer adherence above and beyond both depression (β = .236, t[102] = 2.113, p = .037) and hostility (β = .244, t[102] = 2.506, p = .014). The Medication Abuse scale also completely mediated the relationship between adherence and depression. These findings suggest that personality measures such as the MBMD and hostility scales might be utilized in future studies investigating predictors of adherence and also used clinically to predict medication adherence among HF patients.
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Gattellari M, Leung DY, Ukoumunne OC, Zwar N, Grimshaw J, Worthington JM. Study protocol: the DESPATCH study: delivering stroke prevention for patients with atrial fibrillation - a cluster randomised controlled trial in primary healthcare. Implement Sci 2011; 6:48. [PMID: 21599901 PMCID: PMC3121604 DOI: 10.1186/1748-5908-6-48] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/20/2011] [Indexed: 12/21/2022] Open
Abstract
Background Compelling evidence shows that appropriate use of anticoagulation in patients with nonvalvular atrial fibrillation reduces the risk of ischaemic stroke by 67% and all-cause mortality by 26%. Despite this evidence, anticoagulation is substantially underused, resulting in avoidable fatal and disabling strokes. Methods DESPATCH is a cluster randomised controlled trial with concealed allocation and blinded outcome assessment designed to evaluate a multifaceted and tailored implementation strategy for improving the uptake of anticoagulation in primary care. We have recruited general practices in South Western Sydney, Australia, and randomly allocated practices to receive the DESPATCH intervention or evidence-based guidelines (control). The intervention comprises specialist decisional support via written feedback about patient-specific cases, three academic detailing sessions (delivered via telephone), practice resources, and evidence-based information. Data for outcome assessment will be obtained from a blinded, independent medical record audit. Our primary endpoint is the proportion of nonvalvular atrial fibrillation patients, over 65 years of age, receiving oral anticoagulation at any time during the 12-month posttest period. Discussion Successful translation of evidence into clinical practice can reduce avoidable stroke, death, and disability due to nonvalvular atrial fibrillation. If successful, DESPATCH will inform public policy, providing quality evidence for an effective implementation strategy to improve management of nonvalvular atrial fibrillation, to close an important evidence-practice gap. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000074392
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
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Rose AJ, Berlowitz DR, Frayne SM, Hylek EM. Measuring quality of oral anticoagulation care: extending quality measurement to a new field. Jt Comm J Qual Patient Saf 2009; 35:146-55. [PMID: 19326806 DOI: 10.1016/s1553-7250(09)35019-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun. To address this gap in the literature, a MEDLINE search was conducted for all papers relevant to possible quality measures in oral anticoagulation care, including measures of structure, process, and outcomes of care. LIMITATIONS, CONCERNS, AND CHALLENGES OF QUALITY MEASUREMENT IN ORAL ANTICOAGULATION Because they do not have intrinsic significance, measures of structure and process should be strongly related to outcomes that matter to merit our interest. Consensus guidelines may provide useful guidance to practicing clinicians but may not represent valid process measures. Outcome measures must be studied with databases that provide sufficient statistical power to reliably demonstrate real differences between providers or sites of care. CONCLUSION Oral anticoagulation care, a common and serious condition, is in need of a program of quality measurement. This article suggests a research agenda to begin such a program. Previous research has established the evidence for anticoagulant therapy across a broad spectrum of indications and has helped to achieve consensus on the optimal target intensity for various indications. The next task will be to use this body of evidence to develop valid measures of the structure, process, and outcomes of oral anticoagulation care. Quality indicators provide a framework for quality improvement, two goals of which are to maximize the effectiveness of therapy and to minimize harm.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes and Economic Research, Bedford VA Medical Center, Bedford, MA, USA.
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Gattellari M, Worthington JM, Zwar NA, Middleton S. The management of non-valvular atrial fibrillation (NVAF) in Australian general practice: bridging the evidence-practice gap. A national, representative postal survey. BMC FAMILY PRACTICE 2008; 9:62. [PMID: 19014560 PMCID: PMC2611987 DOI: 10.1186/1471-2296-9-62] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 11/13/2008] [Indexed: 01/15/2023]
Abstract
Background General practitioners (GPs) are ideally placed to bridge the widely noted evidence-practice gap between current management of NVAF and the need to increase anticoagulant use to reduce the risk of fatal and disabling stroke in NVAF. We aimed to identify gaps in current care, and asked GPs to identify potentially useful strategies to overcome barriers to best practice. Methods We obtained contact details for a random sample of 1000 GPs from a national commercial data-base. Randomly selected GPs were mailed a questionnaire after an advance letter. Standardised reminders were administered to enhance response rates. As part of a larger survey assessing GP management of NVAF, we included questions to explore GPs' risk assessment, estimates of stroke risk and GPs' perceptions of the risks and benefits of anticoagulation with warfarin. In addition, we explored GPs' perceived barriers to the wider uptake of anticoagulation, quality control of anticoagulation and their assessment of strategies to assist in managing NVAF. Results 596 out of 924 eligible GPs responded (64.4% response rate). The majority of GPs recognised that the benefits of warfarin outweighed the risks for three case scenarios in which warfarin is recommended according to Australian guidelines. In response to a hypothetical case scenario describing a patient with a supratherapeutic INR level of 5, 41.4% of the 596 GPs (n = 247) and 22.0% (n = 131) would be "highly likely" or "likely", respectively, to cease warfarin therapy and resume at a lower dose when INR levels are within therapeutic range. Only 27.9% (n = 166/596) would reassess the patient's INR levels within one day of recording the supratherapeutic INR. Patient contraindications to warfarin was reported to "usually" or "always" apply to the patients of 40.6% (n = 242/596) of GPs when considering whether or not to prescribe warfarin. Patient refusal to take warfarin "usually" or "always" applied to the patients of 22.3% (n = 133/596) of GPs. When asked to indicate the usefulness of strategies to assist in managing NVAF, the majority of GPs (89.1%, n = 531/596) reported that they would find patient educational resources outlining the benefits and risks of available treatments "quite useful" or "very useful". Just under two-thirds (65.2%; n = 389/596) reported that they would find point of care INR testing "quite" or "very" useful. An outreach specialist service and training to enable GPs to practice stroke medicine as a special interest were also considered to be "quite" or "very useful" by 61.9% (n = 369/596) GPs. Conclusion This survey identified gaps, based on GP self-report, in the current care of NVAF. GPs themselves have provided guidance on the selection of implementation strategies to bridge these gaps. These results may inform future initiatives designed to reduce the risk of fatal and disabling stroke in NVAF.
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales and Centre for Research Management, Evidence and Surveillance Sydney South West Area Health Service, Liverpool, Australia.
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Nelson WL, Han PKJ, Fagerlin A, Stefanek M, Ubel PA. Rethinking the objectives of decision aids: a call for conceptual clarity. Med Decis Making 2007; 27:609-18. [PMID: 17873251 DOI: 10.1177/0272989x07306780] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids--to help patients make informed, preference-sensitive choices--is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids--as they have been conceived and operationalized so far--can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.
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Affiliation(s)
- Wendy L Nelson
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Feldman-Stewart D, Brennenstuhl S, McIssac K, Austoker J, Charvet A, Hewitson P, Sepucha KR, Whelan T. A systematic review of information in decision aids. Health Expect 2007; 10:46-61. [PMID: 17324194 PMCID: PMC5060377 DOI: 10.1111/j.1369-7625.2006.00420.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We completed a systematic review of information reported as included in decision aids (DAs) for adult patients, to determine if it is complete, balanced and accurate. SEARCH STRATEGY DAs were identified using the Cochrane Database of DAs and searches of four electronic databases using the terms: 'decision aid'; shared decision making' and 'patients'; 'multimedia or leaflets or pamphlets or videos and patients and decision making'. Additionally, publications reporting DA development and actual DAs that were reported as publicly available on the Internet were consulted. Publications were included up to May 2006. DATA EXTRACTION Data were extracted on the following variables: external groups consulted in development of the DA, type of study used, categories of information, inclusion of probabilities, use of citation lists and inclusion of patient experiences. MAIN RESULTS 68 treatment DAs and 30 screening DAs were identified. 17% of treatment DAs and 47% of screening DAs did not report any external consultation and, of those that did, DA producers tended to rely more heavily on medical experts than on patients' guidance. Content evaluations showed that (i) treatment DAs frequently omit describing the procedure(s) involved in treatment options and (ii) screening DAs frequently focus on false positives but not false negatives. About 1/2 treatment DAs reported probabilities with a greater emphasis on potential benefits than harms. Similarly, screening DAs were more likely to provide false-positive than false-negative rates. CONCLUSIONS The review led us to be concerned about completeness, balance and accuracy of information included in DAs.
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Affiliation(s)
- Deb Feldman-Stewart
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada.
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Song MK, Sereika SM. An evaluation of the Decisional Conflict Scale for measuring the quality of end-of-life decision making. PATIENT EDUCATION AND COUNSELING 2006; 61:397-404. [PMID: 15970420 DOI: 10.1016/j.pec.2005.05.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Revised: 04/19/2005] [Accepted: 05/05/2005] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Researchers and clinicians acknowledge the complexity of planning for future medical treatment desired in the event of incapacitation. Unfortunately, many attempts to evaluate the quality of such difficult planning have been stymied by the lack of measures that can be shown to have validity. This study examines the psychometric characteristics of the Decisional Conflict Scale (DCS) when used as a measure of patients' evaluation of their end-of-life decision-making process. METHODS This evaluation used the combined data from two independent samples in which 59 outpatients with a life-threatening illness and their surrogate decision makers were assigned to receive, a decision aid intervention, the patient-centered advance care planning (PcACP), or usual care only. RESULTS Internal consistency for the DCS in the end-of-life decision-making context was high. The DCS demonstrated convergent, construct, and discriminant validity based on the total scale scores. CONCLUSION The DCS appears to be a viable research instrument for measuring the quality of end-of-life decision making. However, the uncertainty subscale showed a weak discriminating ability and lack of association with the two other subscales, the modifiable factors contributing to uncertainty and the effectiveness of the decision making. PRACTICE IMPLICATIONS The findings of the study can be useful for measuring decisional conflict in individuals with serious illness facing end-of-life decision making.
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Affiliation(s)
- Mi-Kyung Song
- Department of Acute & Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, 336 VB, Pittsburgh, PA 15261, USA.
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McAlister FA, Man-Son-Hing M, Straus SE, Ghali WA, Anderson D, Majumdar SR, Gibson P, Cox JL, Fradette M. Impact of a patient decision aid on care among patients with nonvalvular atrial fibrillation: a cluster randomized trial. CMAJ 2005; 173:496-501. [PMID: 16129870 PMCID: PMC1188186 DOI: 10.1503/cmaj.050091] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Too few patients with nonvalvular atrial fibrillation (NVAF) receive appropriate antithrombotic therapy. We tested the short-term (primary outcome) and long-term (secondary outcome) effect of a patient decision aid on the appropriateness of antithrombotic therapy among patients with NVAF. METHODS We conducted a cluster randomized trial with blinded outcome assessment involving 434 NVAF patients from 102 community-based primary care practices. Patients in the intervention group received a self-administered booklet and audiotape decision aid tailored to their personal stroke risk profile. Patients in the control group received usual care. The primary outcome measure was change in antithrombotic therapy at 3 months. Appropriateness of therapy was defined using the American College of Chest Physicians (ACCP) recommendations. RESULTS The mean patient age was 72 years, and the median duration of NVAF was 5 years. In the control group, there was a 3% decrease over 3 months in the number of patients receiving therapy appropriate to their risk of stroke (40% [85/215] at baseline v. 37% [79/215] at 3 months). In the intervention group, the number of patients receiving therapy appropriate to their stroke risk increased by 9% (32% [69/219] at baseline v. 41% [89/219] at 3 months). Although the proportion of patients whose therapy met the ACCP treatment recommendations did not differ between study arms at baseline (p = 0.11) or 3 months (p = 0.44), there was a 12% absolute improvement in the number of patients receiving appropriate care in the intervention group compared with the control group at 3 months (p = 0.03). The beneficial effect of the decision aid did not persist (p = 0.44 for differences between study arms after 12 months). INTERPRETATION There was short-term improvement in the appropriateness of antithrombotic care among patients with NVAF who were exposed to a decision aid, but the improvement did not persist.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Alta.
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