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Nguyen TT, Nguyen LH, Nguyen HTT, Dam VAT, Vu TMT, Latkin CA, Zhang MWB, Ho RCM, Ho CSH. Preferences for childbirth delivery and pain relief methods among pregnant women in Vietnam. Front Med (Lausanne) 2024; 11:1290232. [PMID: 38352144 PMCID: PMC10861798 DOI: 10.3389/fmed.2024.1290232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/11/2024] [Indexed: 02/16/2024] Open
Abstract
Background Understanding childbirth delivery and pain relief method preferences is important as a part of the shared decision-making process between pregnant women and health professionals. This study aimed to examine the preferences for childbirth delivery modes and pain relief methods and factors related to these preferences among pregnant women in Vietnam. Methods A cross-sectional survey on pregnant women was conducted in two obstetrics hospitals in Vietnam. Face-to-face interviews using a structured questionnaire were performed to collect information about sociodemographic characteristics, pregnancy characteristics, preferences for different childbirth delivery modes, and pain relief methods. Multivariate logistic regression was employed for determining associated factors with the preferences. Results Of 576 pregnant women, 34% of participants preferred cesarean section. Most of the sample did not have any preferences for specific pharmacological pain relief methods (70.1%), while support from partner/relatives was the most preferable non-pharmacological method (61.3%), following by water birth (11.1%) and acupuncture (9.9%). Desire to have another baby, relatives' experience, selection date of birth, and instrumental social support were major drivers of the cesarean section selection. This preference was an important factor in the preference for pharmacological pain relief. Meanwhile, high levels of informational and emotional support were associated with non-pharmacological method preference. Conclusion This study highlighted a high preference rate for cesarean section in urban pregnant women in Vietnam. Holistic approaches from family, health facility, and policy should be performed to diminish the cesarean rate preference and promote the use of non-pharmacological pain relief methods during birth.
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Affiliation(s)
- Tham Thi Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
- Faculty of Nursing, Duy Tan University, Da Nang, Vietnam
| | - Long Hoang Nguyen
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Vu Anh Trong Dam
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
- Faculty of Nursing, Duy Tan University, Da Nang, Vietnam
| | - Thuc Minh Thi Vu
- Institute of Health Economics and Technology (iHEAT), Hanoi, Vietnam
| | - Carl A. Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Melvyn W. B. Zhang
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Roger C. M. Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Cyrus S. H. Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Ni YS, Sun L, Zhang J, Zhou L, Yang JX, Chen R. Experiences of decisional conflict related to epidural labour analgesia among women during late pregnancy in a tertiary hospital in China: a mixed methods study. Midwifery 2023; 126:103798. [PMID: 37666059 DOI: 10.1016/j.midw.2023.103798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Research has indicated some women were in a state of uncertainty about pharmacological pain management decisions, which may lead to maternal anxiety and decisional regret. However, little is known about decisional conflict in the choice of epidural labour analgesia amongst Chinese women. AIM This study aimed to investigate the level of and reasons underlying decisional conflict in Chinese women during their late pregnancy when making a decision on the use of epidural analgesia in labour. METHODS A convergent parallel mixed methods study was undertaken, that included a quantitative survey (n = 323) and qualitative interviews (n = 17) with women recruited from a tertiary general hospital in Hangzhou, China. The quantitative survey assessed the level of and its influencing factors of women's decisional conflict, while the qualitative interview further explored experiences of and reasons underlying the conflict. FINDINGS Participants reported a high level of decisional conflict (mean±SD, 39.59±15.92), which related to decision delay and/or negative perceptions about the decision. Multiple stepwise linear regression analysis identified that highest level of education and knowledge of epidural were negatively associated with decisional conflict (p<0.05). Four decision-making styles (rational, dependant, intuitive and avoidant decision-making) associated with different levels of decisional conflict, and four underlying reasons (personal characteristics, informational provision, emotional support and participation in decision-making) of the conflict were thematized. CONCLUSION Decisional conflict related to epidural labour analgesia is a noteworthy issue amongst women during their late pregnancy. This study suggests a need for provision of family-centred shared decision-making practice about the use of epidural analgesia in labour.
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Affiliation(s)
- Yi-Sha Ni
- School of Nursing, Hangzhou Normal University, No. 2318, Yu Hang Tang St, Cang Qian Area, Yu Hang Dis, Hangzhou, Zhejiang 311121, China
| | - Li Sun
- Department of Nursing, Hangzhou Fuyang District Vocational High School, No.2, Wen Jiao St, Fu Yang Dis, Hangzhou, Zhejiang 311400, China
| | - Jing Zhang
- School of Nursing, Hangzhou Normal University, No. 2318, Yu Hang Tang St, Cang Qian Area, Yu Hang Dis, Hangzhou, Zhejiang 311121, China; Social Science Laboratory for Research in Early Development and Childcare, Hangzhou Normal University, No. 2318, Yu Hang Tang St, Cang Qian Area, Yu Hang Dis, Hangzhou, Zhejiang, 311121, China.
| | - Lin Zhou
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261, Huan Sha St, Xia Cheng Dis, Hangzhou, Zhejiang 310006, China
| | - Jia-Xun Yang
- School of Nursing, Hangzhou Normal University, No. 2318, Yu Hang Tang St, Cang Qian Area, Yu Hang Dis, Hangzhou, Zhejiang 311121, China
| | - Rui Chen
- School of Nursing, Hangzhou Normal University, No. 2318, Yu Hang Tang St, Cang Qian Area, Yu Hang Dis, Hangzhou, Zhejiang 311121, China
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Waddell A, Goodwin D, Spassova G, Bragge P. "The Terminology Might Be Ahead of Practice": Embedding Shared Decision Making in Practice-Barriers and Facilitators to Implementation of SDM in the Context of Maternity Care. MDM Policy Pract 2023; 8:23814683231199943. [PMID: 37743932 PMCID: PMC10517621 DOI: 10.1177/23814683231199943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/20/2023] [Indexed: 09/26/2023] Open
Abstract
Background. It is a patient's right to be included in decisions about their health care. Implementing shared decision making (SDM) is important to enable active communication between clinicians and patients. Although health policy makers are increasingly mandating SDM implementation, SDM adoption has been slow. This study explored stakeholders' organizational- and system-level barriers and facilitators to implementing policy mandated SDM in maternity care in Victoria, Australia. Method. Twenty-four semi-structured interviews were conducted with participants including clinicians, health service administrators and decision makers, and government policy makers. Data were mapped to the Theoretical Domains Framework to identify barriers and facilitators to SDM implementation. Results. Factors identified as facilitating SDM implementation included using a whole-of-system approach, providing additional implementation resources, correct documentation facilitated by electronic medical records, and including patient outcomes in measurement. Barriers included health service lack of capacity, unclear policy definitions of SDM, and policy makers' lack of resources to track implementation. Conclusion. This is the first study to our knowledge to explore barriers and facilitators to SDM implementation from the perspective of multiple actors following policy mandating SDM in tertiary health services in Australia. The primary finding was that there are concerns that SDM implementation policy is outpacing practice. Nonclinical staff play a crucial role translating policy to practice. Addressing organizational- and system-level barriers and facilitators to SDM implementation should be a key concern of health policy makers, health services, and staff. Highlights New government policies require shared decision making (SDM) implementation in hospitals.There is limited evidence for how to implement SDM in hospital settings.There are concerns SDM implementation policy is outpacing practice.Understanding and capacity for SDM varies considerably among stakeholders.Whole of system approaches and electronic medical records are seen to facilitate SDM.
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Affiliation(s)
- Alex Waddell
- Monash Sustainable Development Institute, Monash University, Clayton, VIC, Australia
- Safer Care Victoria, Victorian Department of Health, Melbourne, VIC, Australia
| | - Denise Goodwin
- Behaviour Works Australia Health Programs, Monash Sustainable Development Institute, Monash University, Clayton, VIC, Australia
| | - Gerri Spassova
- Department of Marketing, Monash Business School, Caulfield East, VIC, Australia
| | - Peter Bragge
- Monash Sustainable Evidence Review Service, Monash Sustainable Development Institute, Monash University, Clayton, VIC, Australia
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A qualitative study of labour pain relief information: what women get, what they want, and how it influences their decisions and satisfaction. Int J Obstet Anesth 2022; 52:103591. [DOI: 10.1016/j.ijoa.2022.103591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/19/2022] [Accepted: 08/02/2022] [Indexed: 11/18/2022]
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Levy KS, Smith MK, Lacroix M, Yudin MH. Patient Satisfaction with Informed Consent for Cesarean and Operative Vaginal Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:785-790. [DOI: 10.1016/j.jogc.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
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Lowe D, Ryan R, Schonfeld L, Merner B, Walsh L, Graham-Wisener L, Hill S. Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. Cochrane Database Syst Rev 2021; 9:CD013373. [PMID: 34523117 PMCID: PMC8440158 DOI: 10.1002/14651858.cd013373.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis. OBJECTIVES To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s). DATA COLLECTION AND ANALYSIS Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events. MAIN RESULTS We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies. AUTHORS' CONCLUSIONS The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.
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Affiliation(s)
- Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Rebecca Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Bronwen Merner
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | | | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
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Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg 2021; 164:S1-S42. [PMID: 33822668 DOI: 10.1177/0194599821996297] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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Affiliation(s)
| | - James Whit Mims
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - John D Cramer
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Dickerson
- NorthShore University Health System, Evanston, Illinois, USA.,University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Adam J Folbe
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Deepa J Galaiya
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna H Messner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Allison Paisley
- University of Pennsylvania Otorhinolaryngology, Philadelphia, Pennsylvania, USA
| | - Ahmad R Sedaghat
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Angela K Sturm
- Angela Sturm, MD, PLLC, Houston, Texas, USA.,University of Texas Medical Branch, Galveston, Texas, USA
| | - Erin M Lambie
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Determinants of the use of nonpharmacological analgesia for labor pain management: a national population-based study. Pain 2021; 161:2571-2580. [PMID: 32569092 DOI: 10.1097/j.pain.0000000000001956] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Besides neuraxial analgesia, nonpharmacological methods are also proposed to help women coping with pain during labor. We aimed to identify the individual and organizational factors associated with the use of nonpharmacological analgesia for labor pain management. Women who attempted vaginal delivery with labor analgesia were selected among participants included in the 2016 National Perinatal Survey, a population-based cross-sectional study. Labor analgesia was studied as neuraxial analgesia alone, nonpharmacological analgesia alone, and neuraxial and nonpharmacological analgesia combined. The associations were studied using multilevel multinomial logistic regression. Among the 9231 women included, 62.4% had neuraxial analgesia alone, 6.4% had nonpharmacological analgesia alone, and 31.2% had both. Nonpharmacological analgesia alone or combined with neuraxial analgesia were both associated with high educational level (adjusted odds ratio 1.55; 95% confidence interval [CI], 1.08-2.23 and 1.39; 95% CI, 1.18-1.63), antenatal preference to deliver without neuraxial analgesia, and public maternity unit status. Nonpharmacological analgesia alone was more frequent among multiparous women, and in maternity units with an anesthesiologist not dedicated to delivery unit (1.57; 95% CI, 1.16-2.12) and with the lowest midwife workload (2.15; 95% CI, 1.43-3.22). Neuraxial and nonpharmacological analgesia combined was negatively associated with inadequate prenatal care (0.70; 95% CI, 0.53-0.94). In France, most women who had nonpharmacological analgesia during labor used it as a complementary method to neuraxial analgesia. The use of nonpharmacological analgesia combined with neuraxial analgesia mainly depends on the woman's preference, but also on socioeconomic factors, quality of prenatal care, and care organization.
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Shishido E, Osaka W, Henna A, Motomura Y, Horiuchi S. Effect of a decision aid on the choice of pregnant women whether to have epidural anesthesia or not during labor. PLoS One 2020; 15:e0242351. [PMID: 33180856 PMCID: PMC7660548 DOI: 10.1371/journal.pone.0242351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Decision aids (DAs) are useful in providing information for decision-making on using epidural anesthesia during birth. To date, there has been little development of DAs for Japanese pregnant women. Herein, we investigated the effect of a DA on the decision of pregnant women whether to have epidural anesthesia or not for labor during vaginal delivery. The primary outcome was changes in mean decision conflict score. METHODS In this non-randomized controlled trial, 300 low-risk pregnant women in an urban hospital were recruited by purposive sampling and assigned to 2 groups: DA (intervention) and pamphlet (control) groups. Control enrollment was started first (until 150 women), followed by intervention enrollment (150 women). Pre-test and post-test scores were evaluated using the Decision Conflict Scale (DCS) for primary outcome, knowledge of epidural anesthesia and satisfaction with decision making for secondary outcomes, and decision of anesthesia usage (i.e., with epidural anesthesia, without epidural anesthesia, or undecided). RESULTS Women in the DA group (n = 149: 1 excluded because she did not return post-test questionnaire) had significantly lower DCS score than those in the pamphlet group (n = 150) (DA: -8.41 [SD 8.79] vs. pamphlet: -1.69 [SD 5.91], p < .001). Knowledge of epidural anesthesia and satisfaction with decision-making scores of women who used the DA were significantly higher than those of women who used the pamphlet (p < .001). Women in the DA group showed a significantly lower undecided rate than those in the pamphlet group. The number of undecided women in the DA group significantly decreased from 30.2% to 6.1% (p < .001), whereas that in the pamphlet group remained largely unchanged from 40.7% to 38.9%. CONCLUSION This study indicates that a DA can be useful in helping women make a decision whether to have epidural anesthesia or not for labor during vaginal delivery.
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Affiliation(s)
- Eri Shishido
- St. Luke’s International University, Tokyo, Japan
| | | | - Ayame Henna
- St. Luke’s International Hospital, Tokyo, Japan
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Sex and gender considerations in implementation interventions to promote shared decision making: A secondary analysis of a Cochrane systematic review. PLoS One 2020; 15:e0240371. [PMID: 33031475 PMCID: PMC7544054 DOI: 10.1371/journal.pone.0240371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/25/2020] [Indexed: 12/03/2022] Open
Abstract
Background Shared decision making (SDM) in healthcare is an approach in which health professionals support patients in making decisions based on best evidence and their values and preferences. Considering sex and gender in SDM research is necessary to produce precisely-targeted interventions, improve evidence quality and redress health inequities. A first step is correct use of terms. We therefore assessed sex and gender terminology in SDM intervention studies. Materials and methods We performed a secondary analysis of a Cochrane review of SDM interventions. We extracted study characteristics and their use of sex, gender or related terms (mention; number of categories). We assessed correct use of sex and gender terms using three criteria: “non-binary use”, “use of appropriate categories” and “non-interchangeable use of sex and gender”. We computed the proportion of studies that met all, any or no criteria, and explored associations between criteria met and study characteristics. Results Of 87 included studies, 58 (66.7%) mentioned sex and/or gender. The most mentioned related terms were “female” (60.9%) and “male” (59.8%). Of the 58 studies, authors used sex and gender as binary variables respectively in 36 (62%) and in 34 (58.6%) studies. No study met the criterion “non-binary use”. Authors used appropriate categories to describe sex and gender respectively in 28 (48.3%) and in 8 (13.8%) studies. Of the 83 (95.4%) studies in which sex and/or gender, and/or related terms were mentioned, authors used sex and gender non-interchangeably in 16 (19.3%). No study met all three criteria. Criteria met did not vary according to study characteristics (p>.05). Conclusions In SDM implementation studies, sex and gender terms and concepts are in a state of confusion. Our results suggest the urgency of adopting a standardized use of sex and gender terms and concepts before these considerations can be properly integrated into implementation research.
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Borrelli S, Evans K, Pallotti P, Evans C, Eldridge J, Spiby H. Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour. J Adv Nurs 2020; 76:3273-3292. [PMID: 32989801 DOI: 10.1111/jan.14555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022]
Abstract
AIMS To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour. DESIGN Mixed-methods systematic review. DATA SOURCES A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected. RESULTS Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent. REVIEW METHODS Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced. CONCLUSION Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth. IMPACT The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.
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Affiliation(s)
- Sara Borrelli
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Kerry Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Phoebe Pallotti
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Helen Spiby
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Shared Decision Making in Surgery: A Meta-Analysis of Existing Literature. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:667-681. [DOI: 10.1007/s40271-020-00443-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Effect of health literacy interventions on pregnancy outcomes: A systematic review. Women Birth 2020; 34:180-186. [PMID: 32094036 DOI: 10.1016/j.wombi.2020.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Low health literacy has been associated with worse health outcomes, but little is known about the effectiveness of health literacy interventions developed for pregnant women. AIM To assess the effectiveness of health literacy interventions on pregnancy outcomes through a systematic review of randomised controlled trials. METHODS Randomised controlled trials that assessed health literacy interventions designed to improve pregnancy outcomes were included. The study protocol was registered with PROSPERO (CRD42018094958). FINDINGS Of the 1512 records initially identified, 13 studies were included. Three reported on decision-aid interventions, six on face-to-face interventions and four on written interventions (including computer-based interventions or information leaflets). The primary outcomes of interest for this systematic review were knowledge (10/13 studies) and health literacy (2/13 studies) with one study not reporting either primary outcome. A significant improvement in knowledge was found across the 10 studies, however the two studies which measured health literacy only assessed health literacy at a single time-point. Secondary outcomes including health behaviours, fetal outcomes and health-service utilisation were reported in 11 studies, with inconsistent results. DISCUSSION Few health literacy interventions have been developed specifically for pregnant women. Although health literacy interventions have the potential to improve knowledge and pregnancy outcomes, current evidence is limited by inconsistent outcomes and measurement, and limited use of health literacy theory to inform intervention design and content. Few studies directly measured health literacy. CONCLUSION More research is needed to properly assess the effect of health literacy interventions on pregnancy outcomes. This research should include consideration of health literacy theory in the development of the interventions.
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Nasiri R, Ranjkesh F, Olfati F, Mafi M. Effect of Individual Counseling on the Participation Rate of Pregnant Mothers in Decision Making on the Treatment Process: Clinical Trial. JOURNAL OF EDUCATION AND COMMUNITY HEALTH 2019. [DOI: 10.29252/jech.6.2.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Leinweber KA, Columbo JA, Kang R, Trooboff SW, Goodney PP. A Review of Decision Aids for Patients Considering More Than One Type of Invasive Treatment. J Surg Res 2019; 235:350-366. [PMID: 30691817 PMCID: PMC10647019 DOI: 10.1016/j.jss.2018.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/29/2018] [Accepted: 09/07/2018] [Indexed: 10/27/2022]
Abstract
With continuous advances in medicine, patients are faced with several medical or surgical treatment options for their health conditions. Decision aids may be useful in helping patients navigate these options and choose based on their goals and values. We reviewed the literature to identify decision aids and better understand the effect on patient decision-making. We identified 107 decision aids designed to help patients make decisions between medical treatment or screening options; 39 decision aids were used to help patients choose between a medical and surgical treatment, and five were identified that aided patients in deciding between a major open surgical procedure and a less invasive option. Many of the decision aids were used to help patients decide between prostate, colorectal, and breast cancer screening or treatment options. Although most decision aids were not associated with a significant effect on the actual decision made, they were largely associated with increased patient knowledge, decreased decisional conflict, more accurate perception of risks, increased satisfaction with their decision, and no increase in anxiety surrounding their decision. These data identify a gap in use of decision aids in surgical decision-making and highlight the potential to help surgical patients make value-based, knowledgeable decisions regarding their treatment.
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Affiliation(s)
| | - Jesse A Columbo
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; VA Quality Scholars Program, Veterans Health Association, White River Junction, Vermont; VA Outcomes Group, Veterans Health Association, White River Junction, Vermont; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Ravinder Kang
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; VA Quality Scholars Program, Veterans Health Association, White River Junction, Vermont; VA Outcomes Group, Veterans Health Association, White River Junction, Vermont; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Spencer W Trooboff
- VA Quality Scholars Program, Veterans Health Association, White River Junction, Vermont; VA Outcomes Group, Veterans Health Association, White River Junction, Vermont; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Philip P Goodney
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; VA Quality Scholars Program, Veterans Health Association, White River Junction, Vermont; VA Outcomes Group, Veterans Health Association, White River Junction, Vermont; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
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Légaré F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner‐Banzhoff N. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2018; 7:CD006732. [PMID: 30025154 PMCID: PMC6513543 DOI: 10.1002/14651858.cd006732.pub4] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review. OBJECTIVES To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies. SELECTION CRITERIA Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs. AUTHORS' CONCLUSIONS It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.
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Affiliation(s)
- France Légaré
- Université LavalCentre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL‐UL)2525, Chemin de la CanardièreQuebecQuébecCanadaG1J 0A4
| | - Rhéda Adekpedjou
- Université LavalDepartment of Social and Preventive MedicineQuebec CityQuebecCanada
| | - Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | - Stéphane Turcotte
- Centre de Recherche du CHU de Québec (CRCHUQ) ‐ Hôpital St‐François d'Assise10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Jennifer Kryworuchko
- The University of British ColumbiaSchool of NursingT201 2211 Wesbrook MallVancouverBritish ColumbiaCanadaV6T 2B5
| | - Ian D Graham
- University of OttawaSchool of Epidemiology, Public Health and Preventative Medicine600 Peter Morand CrescentOttawaONCanada
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Mary C Politi
- Washington University School of MedicineDivision of Public Health Sciences, Department of Surgery660 S Euclid AveSt LouisMissouriUSA63110
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Glyn Elwyn
- Cardiff UniversityCochrane Institute of Primary Care and Public Health, School of Medicine2nd Floor, Neuadd MeirionnyddHeath ParkCardiffWalesUKCF14 4YS
| | - Norbert Donner‐Banzhoff
- University of MarburgDepartment of Family Medicine / General PracticeKarl‐von‐Frisch‐Str. 4MarburgGermanyD‐35039
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Smith MK, Levy KS, Yudin MH. Informed Consent During Labour: Patient and Physician Perspectives. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:614-617. [DOI: 10.1016/j.jogc.2017.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/21/2017] [Indexed: 11/28/2022]
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Lee JS, Pérez-Stable EJ, Gregorich SE, Crawford MH, Green A, Livaudais-Toman J, Karliner LS. Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency. J Gen Intern Med 2017; 32:863-870. [PMID: 28185201 PMCID: PMC5515780 DOI: 10.1007/s11606-017-3983-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/05/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Language barriers disrupt communication and impede informed consent for patients with limited English proficiency (LEP) undergoing healthcare procedures. Effective interventions for this disparity remain unclear. OBJECTIVE Assess the impact of a bedside interpreter phone system intervention on informed consent for patients with LEP and compare outcomes to those of English speakers. DESIGN Prospective, pre-post intervention implementation study using propensity analysis. SUBJECTS Hospitalized patients undergoing invasive procedures on the cardiovascular, general surgery or orthopedic surgery floors. INTERVENTION Installation of dual-handset interpreter phones at every bedside enabling 24-h immediate access to professional interpreters. MAIN MEASURES Primary predictor: pre- vs. post-implementation group; secondary predictor: post-implementation patients with LEP vs. English speakers. Primary outcomes: three central informed consent elements, patient-reported understanding of the (1) reasons for and (2) risks of the procedure and (3) having had all questions answered. We considered consent adequately informed when all three elements were met. KEY RESULTS We enrolled 152 Chinese- and Spanish-speaking patients with LEP (84 pre- and 68 post-implementation) and 86 English speakers. Post-implementation (vs. pre-implementation) patients with LEP were more likely to meet criteria for adequately informed consent (54% vs. 29%, p = 0.001) and, after propensity score adjustment, had significantly higher odds of adequately informed consent (AOR 2.56; 95% CI, 1.15-5.72) as well as of each consent element individually. However, compared to post-implementation English speakers, post-implementation patients with LEP had significantly lower adjusted odds of adequately informed consent (AOR, 0.38; 95% CI, 0.16-0.91). CONCLUSIONS A bedside interpreter phone system intervention to increase rapid access to professional interpreters was associated with improvements in patient-reported informed consent and should be considered by hospitals seeking to improve care for patients with LEP; however, these improvements did not eliminate the language-based disparity. Additional clinician educational interventions and more language-concordant care may be necessary for informed consent to equal that for English speakers.
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Affiliation(s)
- Jonathan S Lee
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA.,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Eliseo J Pérez-Stable
- Office of the Director, National Institute of Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Steven E Gregorich
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA.,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Michael H Crawford
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Adrienne Green
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Livaudais-Toman
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA.,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Leah S Karliner
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA. .,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA, USA.
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Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes‐Rovner M, Llewellyn‐Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017; 4:CD001431. [PMID: 28402085 PMCID: PMC6478132 DOI: 10.1002/14651858.cd001431.pub5] [Citation(s) in RCA: 1210] [Impact Index Per Article: 172.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values. OBJECTIVES To assess the effects of decision aids in people facing treatment or screening decisions. SEARCH METHODS Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008. SELECTION CRITERIA We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids. DATA COLLECTION AND ANALYSIS Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence. MAIN RESULTS We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup. AUTHORS' CONCLUSIONS Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
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Affiliation(s)
- Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
- Ottawa Hospital Research InstituteCentre for Practice Changing Research501 Smyth RdOttawaONCanadaK1H 8L6
| | - France Légaré
- CHU de Québec Research Center, Université LavalPopulation Health and Optimal Health Practices Research Axis10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Krystina Lewis
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | | | - Carol L Bennett
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramAdministrative Services Building, Room 2‐0131053 Carling AvenueOttawaONCanadaK1Y 4E9
| | - Karen B Eden
- Oregon Health Sciences UniversityDepartment of Medical Informatics and Clinical EpidemiologyBICC 5353181 S.W. Sam Jackson Park RoadPortlandOregonUSA97239‐3098
| | - Margaret Holmes‐Rovner
- Michigan State University College of Human MedicineCenter for Ethics and Humanities in the Life SciencesEast Fee Road956 Fee Road Rm C203East LansingMichiganUSA48824‐1316
| | - Hilary Llewellyn‐Thomas
- Dartmouth CollegeThe Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at DartmouthHanoverNew HampshireUSA03755
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Lyndal Trevena
- The University of SydneyRoom 322Edward Ford Building (A27)SydneyNSWAustralia2006
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Eslami S, Aslani A, Tara F, Ghalichi L, Erfanian F, Abu-Hanna A. The impact of a computerized decision aid on empowering pregnant women for choosing vaginal versus cesarean section delivery: study protocol for a randomized controlled trial. Trials 2015; 16:549. [PMID: 26634922 PMCID: PMC4669643 DOI: 10.1186/s13063-015-1070-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/18/2015] [Indexed: 11/30/2022] Open
Abstract
Background Cesarean delivery on maternal request (CDMR) is one of the main reasons for cesarean delivery in Iran, and women often need help in making a decision about the delivery options available to them. The main objective of this study is to evaluate the effect of a computerized decision aid (CDA) system on empowering pregnant women in choosing an appropriate mode of delivery. This CDA contrasts the advantages and disadvantages of vaginal versus cesarean section delivery in terms of their value to the individual woman. Methods/Design The protocol concerns a randomized trial study that will be performed among Iranian women. Four hundred pregnant women will be recruited from two private and two public prenatal centers in Mashhad, Iran. They will be randomly assigned to either an intervention or a control group. The designed CDA will be provided to the intervention group, whereas the control group will only receive routine care. The CDA provides educational contents as well as some recommendations. The CDA’s knowledge base is obtained from the results of studies on predictors of cesarean delivery. The CDA’s software will be installed on women’s computers for use at home. The two primary outcomes for the study are O’Connor’s Decisional Conflict Scale and knowledge as measured by true/false questions. Actual mode of delivery (vaginal versus cesarean) will be compared in the two groups. Discussion We investigate the effect of a CDA on empowering pregnant women in terms of reducing their decisional conflict as well as on improving their clinical knowledge pertaining to mode of delivery. Trial registration This trial is registered with the Iran Trial Registrar under registration number IRCT2015093010777N4 and registration date 26 October 2015.
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Affiliation(s)
- Saeid Eslami
- Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran. .,Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands. .,Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Azam Aslani
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Fatemeh Tara
- Department of Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Leila Ghalichi
- Mental Health Research Centre, Iran University of Medical Sciences, Tehran, Iran.
| | - Fatemeh Erfanian
- Nursing and Midwifery School, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
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Shared decision-making and decision support: their role in obstetrics and gynecology. Curr Opin Obstet Gynecol 2015; 26:523-30. [PMID: 25319001 DOI: 10.1097/gco.0000000000000120] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To discuss the role for shared decision-making in obstetrics/gynecology and to review evidence on the impact of decision aids on reproductive health decision-making. RECENT FINDINGS Among the 155 studies included in a 2014 Cochrane review of decision aids, 31 (29%) addressed reproductive health decisions. Although the majority did not show evidence of an effect on treatment choice, there was a greater uptake of mammography in selected groups of women exposed to decision aids compared with usual care; and a statistically significant reduction in the uptake of hormone replacement therapy among detailed decision aid users compared with simple decision aid users. Studies also found an effect on patient-centered outcomes of care, such as medication adherence, quality-of-life measures, and anxiety scores. In maternity care, only decision analysis tools affected final treatment choice, and patient-directed aids yielded no difference in planned mode of birth after cesarean. SUMMARY There is untapped potential for obstetricians/gynecologists to optimize decision support for reproductive health decisions. Given the limited evidence-base guiding practice, the preference-sensitive nature of reproductive health decisions, and the increase in policy efforts and financial incentives to optimize patients' satisfaction, it is increasingly important for obstetricians/gynecologists to appreciate the role of shared decision-making and decision support in providing patient-centered reproductive healthcare.
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Women's preferences and received pain relief in childbirth – A prospective longitudinal study in a northern region of Sweden. SEXUAL & REPRODUCTIVE HEALTHCARE 2015; 6:74-81. [DOI: 10.1016/j.srhc.2014.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/03/2014] [Accepted: 10/07/2014] [Indexed: 11/21/2022]
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Shorten A, Shorten B. Timing the provision of a pregnancy decision-aid: temporal patterns of preference for mode of birth during pregnancy. PATIENT EDUCATION AND COUNSELING 2014; 97:108-113. [PMID: 25082724 DOI: 10.1016/j.pec.2014.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 06/12/2014] [Accepted: 07/06/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To help identify the optimal timing for provision of pregnancy decision-aids, this paper examines temporal patterns in women's preference for mode of birth after previous cesarean, prior to a decision-aid intervention. METHODS Pregnant women (n=212) with one prior cesarean responded to surveys regarding their preference for elective repeat cesarean delivery (ERCD) or trial of labor (TOL) at 12-18 weeks and again at 28 weeks gestation. Patterns of adherence or change in preference were examined. RESULTS Women's preferences for birth were not set in early pregnancy. There was evidence of increasing uncertainty about preferred mode of birth during the first two trimesters of pregnancy (McNemar value=4.41, p=0.04), decrease in preference for TOL (McNemar value=3.79, p=0.05) and stability in preference for ERCD (McNemar value=0.31, p=0.58). Adherence to early pregnancy choice was associated with previous birth experience, maternal country of birth, emotional state and hospital site. CONCLUSION Women's growing uncertainty about mode of birth prior to 28 weeks indicates potential readiness for a decision-aid earlier in pregnancy. PRACTICE IMPLICATIONS Pregnancy decision-aids affecting mode of birth could be provided early in pregnancy to increase women's opportunity to improve knowledge, clarify personal values and reduce decision uncertainty.
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Légaré F, Stacey D, Turcotte S, Cossi MJ, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner-Banzhoff N. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2014:CD006732. [PMID: 25222632 DOI: 10.1002/14651858.cd006732.pub3] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Shared decision making (SDM) can reduce overuse of options not associated with benefits for all and respects patient rights, but has not yet been widely adopted in practice. OBJECTIVES To determine the effectiveness of interventions to improve healthcare professionals' adoption of SDM. SEARCH METHODS For this update we searched for primary studies in The Cochrane Library, MEDLINE, EMBASE, CINAHL, the Cochrane Effective Practice and Organisation of Care (EPOC) Specialsied Register and PsycINFO for the period March 2009 to August 2012. We searched the Clinical Trials.gov registry and the proceedings of the International Shared Decision Making Conference. We scanned the bibliographies of relevant papers and studies. We contacted experts in the field to identify papers published after August 2012. SELECTION CRITERIA Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies evaluating interventions to improve healthcare professionals' adoption of SDM where the primary outcomes were evaluated using observer-based outcome measures (OBOM) or patient-reported outcome measures (PROM). DATA COLLECTION AND ANALYSIS The three overall categories of intervention were: interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Studies in each category were compared to studies in the same category, to studies in the other two categories, and to usual care, resulting in nine comparison groups. Statistical analysis considered categorical and continuous primary outcomes separately. We calculated the median of the standardized mean difference (SMD), or risk difference, and range of effect across studies and categories of intervention. We assessed risk of bias. MAIN RESULTS Thirty-nine studies were included, 38 randomised and one non-randomised controlled trial. Categorical measures did not show any effect for any of the interventions. In OBOM studies, interventions targeting both patients and healthcare professionals had a positive effect compared to usual care (SMD of 2.83) and compared to interventions targeting patients alone (SMD of 1.42). Studies comparing interventions targeting patients with other interventions targeting patients had a positive effect, as did studies comparing interventions targeting healthcare professionals with usual care (SDM of 1.13 and 1.08 respectively). In PROM studies, only three comparisons showed any effect, patient compared to usual care (SMD of 0.21), patient compared to another patient (SDM of 0.29) and healthcare professional compared to another healthcare professional (SDM of 0.20). For all comparisons, interpretation of the results needs to consider the small number of studies, the heterogeneity, and some methodological issues. Overall quality of the evidence for the outcomes, assessed with the GRADE tool, ranged from low to very low. AUTHORS' CONCLUSIONS It is uncertain whether interventions to improve adoption of SDM are effective given the low quality of the evidence. However, any intervention that actively targets patients, healthcare professionals, or both, is better than none. Also, interventions targeting patients and healthcare professionals together show more promise than those targeting only one or the other.
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Affiliation(s)
- France Légaré
- Population Health and Optimal Health Practices Research Axis, CHU de Québec Research Center, Université Laval, 10 Rue de l'Espinay, D6-727, Québec City, Québec, Canada, G1L 3L5
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Eley V, Donovan K, Walters E, Brijball R, Eley D. The effect of antenatal anaesthetic consultation on maternal decision-making, anxiety level and risk perception in obese pregnant women. Int J Obstet Anesth 2014; 23:118-24. [DOI: 10.1016/j.ijoa.2013.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 10/28/2013] [Accepted: 10/28/2013] [Indexed: 10/26/2022]
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Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JHC. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014:CD001431. [PMID: 24470076 DOI: 10.1002/14651858.cd001431.pub4] [Citation(s) in RCA: 836] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty. OBJECTIVES To assess the effects of decision aids for people facing treatment or screening decisions. SEARCH METHODS For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008). SELECTION CRITERIA We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions. DATA COLLECTION AND ANALYSIS Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model. MAIN RESULTS This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. AUTHORS' CONCLUSIONS There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
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Lally JE, Thomson RG, MacPhail S, Exley C. Pain relief in labour: a qualitative study to determine how to support women to make decisions about pain relief in labour. BMC Pregnancy Childbirth 2014; 14:6. [PMID: 24397421 PMCID: PMC3893516 DOI: 10.1186/1471-2393-14-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 12/16/2013] [Indexed: 11/18/2022] Open
Abstract
Background Engagement in decision making is a key priority of modern healthcare. Women are encouraged to make decisions about pain relief in labour in the ante-natal period based upon their expectations of what labour pain will be like. Many women find this planning difficult. The aim of this qualitative study was to explore how women can be better supported in preparing for, and making, decisions during pregnancy and labour regarding pain management. Methods Semi-structured interviews were conducted with 13 primiparous and 10 multiparous women at 36 weeks of pregnancy and again within six weeks postnatally. Data collection and analysis occurred concurrently to identify key themes. Results Three main themes emerged from the data. Firstly, during pregnancy women expressed a degree of uncertainty about the level of pain they would experience in labour and the effect of different methods of pain relief. Secondly, women reflected on how decisions had been made regarding pain management in labour and the degree to which they had felt comfortable making these decisions. Finally, women discussed their perceived levels of control, both desired and experienced, over both their bodies and the decisions they were making. Conclusion This study suggests that the current approach of antenatal preparation in the NHS, of asking women to make decisions antenatally for pain relief in labour, needs reviewing. It would be more beneficial to concentrate efforts on better informing women and on engaging them in discussions around their values, expectations and preferences and how these affect each specific choice rather than expecting them to make to make firm decisions in advance of such an unpredictable event as labour.
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Affiliation(s)
- Joanne E Lally
- Institute of Health and Society, Baddiley Clark Building, Newcastle University, Baddiley-Clark Building Richardson Road, Newcastle upon Tyne NE2 4AX, United Kingdom.
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Feldman-Stewart D, O’Brien MA, Clayman ML, Davison BJ, Jimbo M, Labrecque M, Martin RW, Shepherd H. Providing information about options in patient decision aids. BMC Med Inform Decis Mak 2013; 13 Suppl 2:S4. [PMID: 24625127 PMCID: PMC4042380 DOI: 10.1186/1472-6947-13-s2-s4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Legal, ethical, and psychological arguments indicate that patients need to receive information about their health situations before their care decisions are made. Patient decision aids (PtDAs) are designed to help patients make decisions; therefore, they should provide information that results in patients understanding their health situation. We reviewed studies that assessed the impact of PtDAs on patient knowledge and on their feeling of being uninformed. METHODS Our data sources were a published Cochrane Collaboration review that included randomized controlled trials (RCTs) published before 2010 and a systematic review we conducted of RCTs published in 2010. We included trials that compared 1) PtDAs to usual care, and 2) PtDAs with simple information to PtDAs with more detailed information. Outcomes included patients' knowledge and their feeling of being uninformed. Data were analyzed quantitatively and qualitatively. Meta-analyses of similar studies estimated the size of differences. RESULTS Thirty-nine RCTs compared a PtDA to usual care and all showed higher knowledge scores for patients in the PtDA groups; a meta-analysis estimated the advantage at 14 (of 100) points. Sixteen (of 39) studies used the Feeling Uninformed subscale; a meta-analysis estimated a reduction of 7 (of 100) points in the PtDA group over usual care. Twenty-one studies compared simple- to more-detailed information in PtDAs. There was a small overall advantage for more detailed information on knowledge scores; a meta-analysis estimated the advantage at 5 (of 100) points. Only one study found higher mean knowledge scores for simpler information. Nine (of 21) studies reported using the Feeling Uninformed subscale and a meta-analysis suggested a reduction of 3 (of 100) points for the more-detailed PtDAs over those with simpler information. Only one study found that simpler information resulted in patients feeling more informed. CONCLUSIONS It appears that PtDAs result in patients having higher knowledge scores and in reduced feelings of being uninformed over patients who receive usual care. It also appears that PtDAs with more detailed information generally result in slightly higher knowledge and lower "Feeling Uninformed" scores than those with simpler information, but the differences are small and can be reversed under some circumstances.
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Affiliation(s)
- Deb Feldman-Stewart
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Level 2, 10 Stuart St. Kingston, Ontario K7L 3N6, Canada
| | - Mary Ann O’Brien
- Knowledge Translation Research Network (KT-Net), Health Services Research Program, Cancer Care Ontario and Ontario Institute for Cancer Research and Department of Family and Community Medicine, 500 University Avenue, Fifth Floor, Toronto, Ontario M5G 1V7, Canada
| | - Marla L Clayman
- Division of General Internal Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 750 North Lake Shore Drive, 10th Floor, Chicago, Illinois 60611, USA
| | - B Joyce Davison
- College of Nursing, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Masahito Jimbo
- Department of Family Medicine, University of Michigan, 1500 E Medical Center Drive, Spc 5474, Ann Arbor, MI 48104, USA
| | - Michel Labrecque
- Research Center of the Centre hospitalier universitaire de Québec, Saint-François d'Assise Hospital, 10 rue de l'Espinay, D6-728, Quebec City (QC), G1L 3L5, Canada
| | - Richard W Martin
- College of Human Medicine, Michigan State University, 1155 East Paris Ave SE Suite 100, Grand Rapids, MI 49546, USA
| | - Heather Shepherd
- Sydney School of Public Health, The University of Sydney, Sydney NSW 2006, Australia
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Kinnersley P, Phillips K, Savage K, Kelly MJ, Farrell E, Morgan B, Whistance R, Lewis V, Mann MK, Stephens BL, Blazeby J, Elwyn G, Edwards AGK. Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. Cochrane Database Syst Rev 2013:CD009445. [PMID: 23832767 DOI: 10.1002/14651858.cd009445.pub2] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken. However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions. There is evidence that at present some patients undergo procedures without informed consent being achieved. OBJECTIVES To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures. SEARCH METHODS We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies. SELECTION CRITERIA Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided. DATA COLLECTION AND ANALYSIS Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data. MAIN RESULTS We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias. More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process. Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. AUTHORS' CONCLUSIONS Informed consent is an important ethical and practical part of patient care. We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent. The interventions used consistently improve patient knowledge, an important prerequisite for informed consent. This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.
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Affiliation(s)
- Paul Kinnersley
- Cochrane Institute of Primary Care and Public Health, School ofMedicine, Cardiff University, Cardiff, UK.
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Hidaka R, Callister LC. Giving birth with epidural analgesia: the experience of first-time mothers. J Perinat Educ 2013; 21:24-35. [PMID: 23277728 DOI: 10.1891/1058-1243.21.1.24] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of our qualitative descriptive study was to describe the birth experiences of women using epidural analgesia for pain management. We interviewed nine primiparas who experienced vaginal births. Five themes emerged: (a) coping with pain, (b) finding epidural administration uneventful, (c) feeling relief having an epidural, (d) experiencing joy, and (e) having unsettled feelings of ambivalence. Although epidural analgesia was found to be effective for pain relief and may contribute to some women's satisfaction with the birth experience, it does not guarantee a quality birth experience. In order to support and promote childbearing women's decision making, we recommend improved education on the variety of available pain management options, including their risks and benefits. Fostering a sense of caring, connection, and control in women is a key factor to ensure positive birth experiences, regardless of pain management method.
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Vlemmix F, Warendorf JK, Rosman AN, Kok M, Mol BWJ, Morris JM, Nassar N. Decision aids to improve informed decision-making in pregnancy care: a systematic review. BJOG 2012; 120:257-66. [PMID: 23145991 DOI: 10.1111/1471-0528.12060] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 11/29/2022]
Affiliation(s)
- F Vlemmix
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam; the Netherlands
| | - JK Warendorf
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam; the Netherlands
| | - AN Rosman
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam; the Netherlands
| | - M Kok
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam; the Netherlands
| | - BWJ Mol
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam; the Netherlands
| | - JM Morris
- The University of Sydney; Royal North Shore Hospital; St Leonards; NSW; Australia
| | - N Nassar
- Kolling Institute of Medical Research; University of Sydney; St Leonards; NSW; Australia
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Stirling C, Leggett S, Lloyd B, Scott J, Blizzard L, Quinn S, Robinson A. Decision aids for respite service choices by carers of people with dementia: development and pilot RCT. BMC Med Inform Decis Mak 2012; 12:21. [PMID: 22429384 PMCID: PMC3315425 DOI: 10.1186/1472-6947-12-21] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 03/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decision aids are often used to assist individuals confronted with a diagnosis of a serious illness to make decisions about treatment options. However, they are rarely utilised to help those with chronic or age related conditions to make decisions about care services. Decision aids should also be useful for carers of people with decreased decisional capacity. These carers' choices must balance health outcomes for themselves and for salient others with relational and value-based concerns, while relying on information from health professionals. This paper reports on a study that both developed and pilot tested a decision aid aimed at assisting carers to make evaluative judgements of community services, particularly respite care. METHODS A mixed method sequential study, involving qualitative development and a pilot randomised controlled trial, was conducted in Tasmania, Australia. We undertook 13 semi-structured interviews and three focus groups to inform the development of the decision aid. For the randomised control trial we randomly assigned 31 carers of people with dementia to either receive the service decision aid at the start or end of the study. The primary outcome was measured by comparing the difference in carer burden between the two groups three months after the intervention group received the decision aid. Pilot data was collected from carers using interviewer-administered questionnaires at the commencement of the project, two weeks and 12 weeks later. RESULTS The qualitative data strongly suggest that the intervention provides carers with needed decision support. Most carers felt that the decision aid was useful. The trial data demonstrated that, using the mean change between baseline and three month follow-up, the intervention group had less increase in burden, a decrease in decisional conflict and increased knowledge compared to control group participants. CONCLUSIONS While these results must be interpreted with caution due to the small sample size, all intervention results trend in a direction that is beneficial for carers and their decisional ability. Mixed method data suggest the decision aid provides decisional support that carers do not otherwise receive. Decision aids may prove useful in a community health services context. TRIAL REGISTRATION NUMBER ISRCTN: ISRCTN32163031.
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Affiliation(s)
- Christine Stirling
- Wicking Dementia Research and Education Centre, Menzies Research Institute, University of Tasmania, Private Bag 121, Hobart, TAS, Australia 7000
- School of Nursing and Midwifery, University of Tasmania, 24 Campbell St, Tasmania, Australia
| | - Susan Leggett
- Wicking Dementia Research and Education Centre, Menzies Research Institute, University of Tasmania, Private Bag 121, Hobart, TAS, Australia 7000
| | - Barbara Lloyd
- Wicking Dementia Research and Education Centre, Menzies Research Institute, University of Tasmania, Private Bag 121, Hobart, TAS, Australia 7000
| | - Jenn Scott
- School of Psychology, University of Tasmania, Sandy Bay Campus, Tasmania, Australia
| | - Leigh Blizzard
- Menzies Research Institute, University of Tasmania, 17 Liverpool St, Hobart, Australia
| | - Stephen Quinn
- Flinders Clinical Effectiveness, Flinders University, Adelaide, Australia
| | - Andrew Robinson
- Wicking Dementia Research and Education Centre, Menzies Research Institute, University of Tasmania, Private Bag 121, Hobart, TAS, Australia 7000
- School of Nursing and Midwifery, University of Tasmania, 24 Campbell St, Tasmania, Australia
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Derry S, Straube S, Moore RA, Hancock H, Collins SL. Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour. Cochrane Database Syst Rev 2012; 1:CD009107. [PMID: 22258999 DOI: 10.1002/14651858.cd009107.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intracutaneous or subcutaneous injection of sterile water is rapidly gaining popularity as a method of pain relief in labour and it is therefore essential that it is properly evaluated. Adequate analgesia in labour is important to women worldwide. Sterile water injection is inexpensive, requires basic equipment, and appears to have few side effects. It is purported to work for labour pain. OBJECTIVES To determine the efficacy of sterile water injections for relief of pain (both typical contraction pain and intractable back pain) during labour compared to placebo (isotonic saline injections) or non-pharmacological interventions, and to identify any relevant effects on mode and timing of delivery, or safety of both mother and baby. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2011), MEDLINE, and EMBASE (January 2010 to 30 May 2011), together with reference lists in retrieved studies and review articles. SELECTION CRITERIA We included randomised, double blind, controlled studies using intracutaneous or subcutaneous sterile water injections for pain relief during labour. There were no restrictions on birth place, parity, risk, age, weight, gestation, or stage of labour. Potential comparators were placebo (saline) and non-pharmacological interventions (e.g. hypnosis or biofeedback). DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and quality of trials, and extracted data. We resolved any disagreements or uncertainties by discussion with a third review author. Primary outcome measures were at least 50% pain relief, or at least 30%, pain relief, patient global impression of change of at least 'good', mode of delivery, perinatal morbidity and mortality, maternal complications and adverse events. Secondary outcomes were women with any pain relief, use of rescue analgesia, and treatment group average pain relief. We made explicit judgements about potential biases in the studies. MAIN RESULTS We included seven studies, with 766 participants: four used intracutaneous injections, two subcutaneous, and one both. All reported on low back pain in labour only. Methodological quality was good, but four studies were at high risk of bias due to small size of treatment groups, incomplete outcome data, and performance bias.All studies reported treatment group mean or median scores, finding greater reduction in pain for sterile water. However, failure to demonstrate a normal distribution for pain intensity or relief, and use of different scales, meant meta-analysis was inappropriate. No study reported primary dichotomous efficacy outcomes. One reported the number self-scoring 4/10 cm or more reduction in pain; significantly more had this outcome with sterile water (50% to 60%) than with placebo (20% to 25%).There was no significant difference between sterile water and saline for rates of caesarean section (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.33 to 1.02), instrumental delivery (RR 1.31, 95% CI 0.79 to 2.18), rescue analgesia (RR 0.86, 95% CI 0.44 to 1.69), timing of delivery, or Apgar scores. Two studies reported that more women treated with sterile water would request the same analgesia in future.No study reported on women's satisfaction with pain relief, women's sense of control in labour, women's satisfaction with the childbirth experience, mother/baby interaction, rates of breastfeeding, maternal morbidity, infant long-term outcomes, or cost. No adverse events were reported other than transient pain with injection, which was worse with sterile water. AUTHORS' CONCLUSIONS The outcomes reported severely limit conclusions for clinical practice. We found little robust evidence that sterile water is effective for low back or any other labour pain. Neither did we find any difference in delivery or other maternal or fetal outcomes. Further large, methodologically rigorous studies are required to determine the efficacy of sterile water to relieve pain in labour.
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Affiliation(s)
- Sheena Derry
- Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), University of Oxford, Oxford,UK.
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Patel SR, Wisner KL. Decision making for depression treatment during pregnancy and the postpartum period. Depress Anxiety 2011; 28:589-95. [PMID: 21681871 PMCID: PMC3128653 DOI: 10.1002/da.20844] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 05/02/2011] [Accepted: 05/04/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To explore women's perspectives about the treatment decision-making process for depression during pregnancy and after birth. METHOD One hundred pregnant and postpartum women completed an anonymous web-based surveys regarding treatment decision making for depression. RESULTS Survey data reveal that most women in this sample prefer an active collaborative role in treatment decision making for depression. Sixty-five percent of the sample made a decision for treatment of their major depressive disorder, including a decision for no treatment, and 34% reported not having made a decision or feeling unsure about their decision. More than half of the sample preferred combination treatment with medications and counseling (55%) followed by counseling (22%), no treatment (8%), and medications (8%). Overall, respondents in this sample had low levels of decisional conflict (uncertainty) with younger women in the sample reporting higher levels of decisional conflict. CONCLUSIONS Treatment decision making for depression during the perinatal period is complex. Asking women about their preferences for participation in decision making, their treatment preferences and their decision making needs during the clinical encounter may lead to improved communication, decision making and quality of care.
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Affiliation(s)
- Sapana R. Patel
- New York State Psychiatric Institute Columbia University, College of Physicians and Surgeons
| | - Katherine L. Wisner
- Women's Behavioral HealthCARE Western Psychiatric Institute and Clinic University of Pittsburgh School of Medicine
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Derry S, Straube S, Moore RA, Hancock H, Collins SL. Intracutaneous or subcutaneous sterile water injection for relieving pain in labour. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009107] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Peate M, Meiser B, Friedlander M, Zorbas H, Rovelli S, Sansom-Daly U, Sangster J, Hadzi-Pavlovic D, Hickey M. It's now or never: fertility-related knowledge, decision-making preferences, and treatment intentions in young women with breast cancer--an Australian fertility decision aid collaborative group study. J Clin Oncol 2011; 29:1670-7. [PMID: 21444865 DOI: 10.1200/jco.2010.31.2462] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE For many young women with early breast cancer, fertility is a priority. Interventions to retain fertility options generally need to be accessed before chemotherapy, but many women do not receive information regarding these options in a timely fashion. Knowledge about fertility and decisional conflict has not previously been measured in young patients with breast cancer considering future pregnancies. METHODS One hundred eleven young women with early breast cancer who had not yet completed their families were recruited around the time of diagnosis. Knowledge regarding fertility-related information, decisional conflict, and preferences regarding fertility information and decision making was measured. RESULTS From a potential fertility-related knowledge score of 10, the mean was 5.2 (standard deviation = 2.3; range, 0 to 10). Decreased knowledge was associated with increased decisional conflict about pursuing fertility preserving interventions (odds ratio [OR] = 0.57; 95% CI, 0.44 to 0.73; P < .001). Thirty-one percent of women reported that they would consider undertaking in vitro fertilization (IVF) as a method to conserve their fertility, whereas 38% were uncertain. Consideration of IVF was not related to whether subjects were in a committed relationship (OR = 1.20; P = .716) or a definite desire for more children (OR = 1.54; P = .513). CONCLUSION Around diagnosis, many young patients with breast cancer have low levels of knowledge about fertility issues. Further, low knowledge is associated with increased decisional conflict, which is likely to undermine the quality of decision making. These findings suggest that targeted and timely fertility information may reduce decisional conflict and increase informed choice. Neither relationship status nor firm plans regarding future children reliably predict desire to pursue fertility preservation.
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Affiliation(s)
- Michelle Peate
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia.
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Say R, Robson S, Thomson R. Helping pregnant women make better decisions: a systematic review of the benefits of patient decision aids in obstetrics. BMJ Open 2011; 1:e000261. [PMID: 22189349 PMCID: PMC3334824 DOI: 10.1136/bmjopen-2011-000261] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objectives Patient decision aids can be used to support pregnant women engaging in shared decisions, but little is known about their effects in obstetrics. The authors aimed to evaluate the effects of patient decision aids designed for pregnant women on clinical and psychosocial outcomes. Design Systematic review. Data on all outcomes were extracted and summarised. All studies were critically appraised for potential sources of bias and, when possible to obtain, the reported decision aids were evaluated. Meta-analysis was not possible due to the heterogeneity of outcomes in primary studies and the small number of studies. Data sources Electronic searches were performed using Medline, Embase, the Cochrane Library and Medion databases from inception until December 2010. Reference lists of all included articles were also examined and key experts contacted. Eligibility criteria for selecting studies Eligibility criteria included randomised controlled trials, which reported on patient decision aids for women facing any treatment decision in pregnancy published in English. Studies evaluating health education material that did not address women's values and preferences were excluded. Results Patient decision aids have been developed for decisions about prenatal testing, vaginal birth after Caesarean section, external cephalic version and labour analgesia. Use of decision aids is associated with a number of positive effects including reduced anxiety, lower decisional conflict, improved knowledge, improved satisfaction and increased perception of having made an informed choice. Conclusions Patient decision aids have the potential to improve obstetric care. However, currently the evidence base is limited by the small number of studies, the quality of the studies and because they involved heterogeneous decision aids, patient groups and outcomes.
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Affiliation(s)
- Rebecca Say
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Stephen Robson
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
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