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Krebs ED, Hoang SC. Informed Consent and Shared Decision Making in the Perioperative Environment. Clin Colon Rectal Surg 2023; 36:223-228. [PMID: 37113280 PMCID: PMC10125277 DOI: 10.1055/s-0043-1761158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Informed consent and shared decision making (SDM) are crucial portions of preoperative patient management. Informed consent is a standard for surgery from both a legal and ethical standpoint, involving disclosure of potential risks of a procedure and ensuring patient understanding of these risks. SDM is a process in which a clinician and patients decide between two or more treatment plans, taking into account the patient's goals and values. SDM is a particularly important aspect of patient-centered care when two or more treatment options exist or in situations where an indicated treatment may not align with the patient's long-term goals. This article details aspects of and issues surrounding informed consent and SDM.
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Affiliation(s)
- Elizabeth D. Krebs
- Department of Surgery, Vanderbilt University Medical Center, Nashville Tennessee
| | - Sook C. Hoang
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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Williams A, Cunningham A, Hutchings H, Harris DA, Evans MD, Harji D. Quality of internet information to aid patient decision making in locally advanced and recurrent rectal cancer. Surgeon 2022; 20:e382-e391. [PMID: 35033455 DOI: 10.1016/j.surge.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/25/2021] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND To review whether online decision aids are available for patients contemplating pelvic exenteration (PE) for locally advanced and recurrent rectal cancer (LARC and LRRC). METHODS A grey literature review was carried out using the Google Search™ engine undertaken using a predefined search strategy (PROSPERO database CRD42019122933). Written health information was assessed using the DISCERN criteria and International Patient Decision Aids Standards (IPDAS) with readability content assessed using the Flesch-Kincaid reading ease test and Flesch-Kincaid grade level score. RESULTS Google search yielded 27, 782, 200 results for the predefined search criteria. 131 sources were screened resulting in the analysis of 6 sources. No sources were identified as a decision aid according to the IPDAS criteria. All sources provided an acceptable quality of written health information, scoring a global score of 3 for the DISCERN written assessment. The median Flesch-Kincaid reading ease was 50.85 (32.5-80.8) equating to a reading age of 15-18 years and the median Flesch-Kincaid grade level score was 7.65 (range 3-9.7), which equates to a reading age of 13-14. CONCLUSIONS This study has found that there is a paucity of online information for patients contemplating PE. Sources that are available are aimed at a high health literate patient. Given the considerable morbidity associated with PE surgery there is a need for high quality relevant information in this area. A PDA should be developed to improve decision making and ultimately improve patient experience.
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Affiliation(s)
- A Williams
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK; Swansea University Medical School, Institute of Life Science 2, Swansea, SA2 8QA, UK.
| | - A Cunningham
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK; Swansea University Medical School, Institute of Life Science 2, Swansea, SA2 8QA, UK.
| | - H Hutchings
- Swansea University Medical School, Institute of Life Science 2, Swansea, SA2 8QA, UK.
| | - D A Harris
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK.
| | - M D Evans
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK.
| | - D Harji
- Population Health Sciences, University of Newcastle, Australia.
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Hommes S, Vromans R, Clouth F, Verbeek X, de Hingh I, Krahmer E. Communication in decision aids for stage I-III colorectal cancer patients: a systematic review. BMJ Open 2021; 11:e044472. [PMID: 33926980 PMCID: PMC8094367 DOI: 10.1136/bmjopen-2020-044472] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To assess the communicative quality of colorectal cancer patient decision aids (DAs) about treatment options, the current systematic review was conducted. DESIGN Systematic review. DATA SOURCES DAs (published between 2006 and 2019) were identified through academic literature (MEDLINE, Embase, CINAHL, Cochrane Library and PsycINFO) and online sources. ELIGIBILITY CRITERIA DAs were only included if they supported the decision-making process of patients with colon, rectal or colorectal cancer in stages I-III. DATA EXTRACTION AND SYNTHESIS After the search strategy was adapted from similar systematic reviews and checked by a colorectal cancer surgeon, two independent reviewers screened and selected the articles. After initial screening, disagreements were resolved with a third reviewer. The review was conducted in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DAs were assessed using the International Patient Decision Aid Standards (IPDAS) and Communicative Aspects (CA) checklist. RESULTS In total, 18 DAs were selected. Both the IPDAS and CA checklist revealed that there was a lot of variation in the (communicative) quality of DAs. The findings highlight that (1) personalisation of treatment information in DAs is lacking, (2) outcome probability information is mostly communicated verbally and (3) information in DAs is generally biased towards a specific treatment. Additionally, (4) DAs about colorectal cancer are lengthy and (5) many DAs are not written in plain language. CONCLUSIONS Both instruments (IPDAS and CA) revealed great variation in the (communicative) quality of colorectal cancer DAs. Developers of patient DAs should focus on personalisation techniques and could use both the IPDAS and CA checklist in the developmental process to ensure personalised health communication and facilitate shared decision making in clinical practice.
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Affiliation(s)
- Saar Hommes
- Tilburg center for Cognition and Communication (TiCC), Tilburg School of Humanities and Digital Sciences (TSHD), Department of Communication and Cognition, Tilburg University, Tilburg, The Netherlands
- The Netherlands Comprehensive Cancer Organization, Department of Research & Development, IKNL, Eindhoven, The Netherlands
| | - Ruben Vromans
- Tilburg center for Cognition and Communication (TiCC), Tilburg School of Humanities and Digital Sciences (TSHD), Department of Communication and Cognition, Tilburg University, Tilburg, The Netherlands
- The Netherlands Comprehensive Cancer Organization, Department of Research & Development, IKNL, Eindhoven, The Netherlands
| | - Felix Clouth
- The Netherlands Comprehensive Cancer Organization, Department of Research & Development, IKNL, Eindhoven, The Netherlands
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
| | - Xander Verbeek
- The Netherlands Comprehensive Cancer Organization, Department of Research & Development, IKNL, Eindhoven, The Netherlands
| | - Ignace de Hingh
- Catharina Cancer Institute, Colorectal Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Emiel Krahmer
- Tilburg center for Cognition and Communication (TiCC), Tilburg School of Humanities and Digital Sciences (TSHD), Department of Communication and Cognition, Tilburg University, Tilburg, The Netherlands
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Sahl S, Pontoriero MI, Hill C, Knoepke CE. Stakeholder perspectives on the implementation of shared decision making to empower youth who have experienced commercial sexual exploitation. CHILDREN AND YOUTH SERVICES REVIEW 2021; 122:105894. [PMID: 34446975 PMCID: PMC8386426 DOI: 10.1016/j.childyouth.2020.105894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Shared decision making (SDM) has been proposed as a method to improve treatment adherence, placement stability, and other youth-centric outcomes for children who have been victims of commercial sexual exploitation (CSEC). This project seeks to characterize service providers' perspectives on the adoption and implementation of SDM into treatment and placement planning decisions. METHOD Sixteen key stakeholders who provide services for youth who have experienced CSEC in a Southern city, as well as adults who survived exploitation as children, were individually interviewed. These interviews focused on stakeholders' perspective on the appropriateness and contextual considerations regarding implementing this model to engage youth in decision-making conversations. Interview transcripts were qualitatively analyzed using group-based inductive content analysis. RESULT While all participants acknowledged the philosophical importance of including youth in decision-making, perspectives varied on how this philosophy could be operationalized. Trauma-bonds to offenders, distrust in service systems, and policy and time constraints were discussed as potential barriers to implementation. Perceived benefits to applying this model included encouraging youth empowerment, helping youth develop decision-making skills, and strengthening relationships between youth and providers. Implementation considerations mirrored those seen in other medical and behavioral health settings, including extensive training, fidelity monitoring, enforcement through policy and legislation, and ultimately resetting the culture of services to be maximally youth inclusive. CONCLUSION Participants supported the use of SDM to standardize the inclusion of youth in treatment and placement planning decisions. However, there exist challenges in defining exactly how to adopt this approach, and how to implement broad-scale cultural change within the service-providing community.
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Affiliation(s)
- Samantha Sahl
- National Center for Missing and Exploited Children, Alexandria, VA, USA
- USC Dworak-Peck School of Social Work, CA, USA
| | - Maria Isabella Pontoriero
- Children’s Hospital New Orleans, New Orleans, LA, USA
- Tulane University School of Social Work, New Orleans, LA, USA
| | - Chloe Hill
- Tulane University School of Social Work, New Orleans, LA, USA
| | - Christopher E. Knoepke
- Division of Cardiology, University of Colorado School of Medicine, Denver, CO, USA
- Adult & Child Consortium for Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Denver, CO, USA
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Lewis KB, Graham ID, Boland L, Stacey D. Writing a compelling integrated discussion: a guide for integrated discussions in article-based theses and dissertations. Int J Nurs Educ Scholarsh 2021; 18:ijnes-2020-0057. [PMID: 33657283 DOI: 10.1515/ijnes-2020-0057] [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: 06/16/2020] [Accepted: 01/08/2021] [Indexed: 11/15/2022]
Abstract
Article-based theses and dissertations are increasingly being used in nursing and the health sciences as an alternate format to the traditional five-chapter monograph. A unique chapter in the article-based thesis is the integrated discussion, which differs in breadth and depth as compared to the discussion for a traditional thesis monograph or journal article. For many students and faculty, the integrated discussion is a challenging chapter to write, with minimal or no published guidance available. In this article, we offer a four-step approach with templates for planning and writing an integrated discussion. We also share several lessons learned with examples from published theses and dissertations. Writing an integrated discussion can be facilitated and written more efficiently by developing a clear and detailed outline of the chapter and broad discussion points prior to drafting the text, to achieve a higher-level synthesis, analysis, and interpretation of the overall significance of the thesis findings.
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Affiliation(s)
- Krystina B Lewis
- School of Nursing, University of Ottawa, Ottawa, ON, Canada.,University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Ian D Graham
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Laura Boland
- Ottawa Hospital Research Institute, Ottawa, Canada.,Western University, London, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
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Chan KH, Misseri R, Carroll A, Frankel RM, Moore C, Cockrum B, Wiehe S. User testing of a hypospadias decision aid prototype at a pediatric medical conference. J Pediatr Urol 2020; 16:685.e1-685.e8. [PMID: 32919901 PMCID: PMC8788200 DOI: 10.1016/j.jpurol.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Based on our previous qualitative work, we created a web-based decision aid (DA) prototype to facilitate shared decision-making regarding hypospadias. OBJECTIVE The objective of this study was to obtain rapid feedback on the prototype as part of an iterative, human-centered design process. METHODS We conducted this study at a statewide, pediatric educational conference in May 2019, recruiting attendees by verbal/written announcements. The DA consisted of: hypospadias overview and surgery "storyboard," frequently asked questions, parent testimonials, and a values clarification exercise. Participants viewed the DA on a tablet as they participated in semi-structured, qualitative interviews covering website acceptability, usability, and preference for surgical photographs versus illustrations. Three coders used qualitative content analysis to identify themes and resolved disagreements by consensus. RESULTS Of 295 conference attendees, all 50 who approached us agreed to participate. Responses from 49 participants were available for analysis: 67% female, ages 20-69, 65% Caucasian, 55% MDs. 96% of participants thought the website design matched its purpose; 59.1% preferred surgical illustrations, 8.2% preferred photos, 30.6% preferred both and 2.0% did not like either. Participants recommended improvements in: a) usability/accessibility (e.g. site navigation, visual layout, page length), b) content coverage (e.g. epidemiology, consequences of no/delayed surgery, lifelong risks), c) parent-centeredness (e.g. reading level/writing style) and d) implementation (provider tools, printable handouts). The Extended Summary Figure shows a revised image of the first step of a hypospadias repair based on feedback about participants' preferences for illustrations rather than photographs. DISCUSSION The main strength of our study was the valuable feedback we obtained to inform critical revisions of the DA prototype. We also demonstrated the feasibility and efficacy of a conducting a usability evaluation of a web-based DA in a medical conference setting. One limitation of this study is that the relatively small population sampled limits generalizability and our findings may not reflect the views of all providers who care for hypospadias patients. CONCLUSIONS The vast majority of providers thought that the design of the Hypospadias Homepage matched its purpose and most preferred surgical illustrations rather than photos to demonstrate the steps of hypospadias surgery. Based on their feedback, we plan to focus our efforts in the following areas: 1) improvement of navigation/menus, 2) reduction in the amount of text per page, 3) expansion of specific content coverage and 4) inclusion of "parent-friendly" visuals such as infographics to represent quantitative data and colorful illustrations to depict hypospadias and its surgical repair.
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Affiliation(s)
- Katherine H Chan
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Pediatrics: Center for Pediatric and Adolescent Comparative Effectiveness Research Indianapolis, IN, USA.
| | - Rosalia Misseri
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Aaron Carroll
- Department of Pediatrics: Center for Pediatric and Adolescent Comparative Effectiveness Research Indianapolis, IN, USA.
| | - Richard M Frankel
- Department of Medicine, Indiana University School of Medicine, Indiana and Cleveland Clinic Learner Institute, Indianapolis, Cleveland, OH, USA.
| | - Courtney Moore
- Research Jam (Patient Engagement Core), Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine Indianapolis, IN, USA.
| | - Brandon Cockrum
- Research Jam (Patient Engagement Core), Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine Indianapolis, IN, USA.
| | - Sarah Wiehe
- Children's Health Services Research Center, Indiana University School of Medicine, Indianapolis, IN, USA; Research Jam (Patient Engagement Core), Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine Indianapolis, IN, USA.
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Patients Decision Aid System Based on FHIR Profiles. J Med Syst 2018; 42:166. [PMID: 30066031 DOI: 10.1007/s10916-018-1016-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
Patients are becoming more and more involved in clinical decision-making process. Several factors support this process. Advances in omics allows individualization of diagnosis and treatment. Patient awareness and easy availability of data on the Internet allows patients to become informed decision makers when it comes even to disease management. Mass media emphasize the issue of medical errors, making patients demanding for quality in medical care. In some healthcare settings, patents face a problem of interpreting medical data and making decisions on treatment tactics without having a doctor, who could potentially support them. Delegating this task to a Patient Decision Aide system can add automatically generated recommendations to result reports without adding significant workload on the doctors, increase patients' motivation and support their decisions. We have implemented a patient decision aid system based on the productions rules, which: Collects data from available sources; Automatically analyses and interprets laboratory test results; Recommends running additional tests for a more precise diagnostic; Delivers automatically generated reports to doctors and patients in a natural language. To achieve semantic interoperability with other systems we have implemented a FHIR engine. The knowledge base has been organized as a graph structure. The application is structured as a set of lightly coupled services, which implement the logic of the decision support system. In total, we have modelled 365 nodes of test components, 5084 nodes of inference rules, 49932 connections and 3072 blocks of text for medical certificates. The findings of the research provide a deep understanding of how the semantically interoperable clinical decision support systems are implemented. Advances in notification the patients with the elements of patient decision aid is important for clinical data management, and for patients' empowerment and protection. We suppose that the system empowering patients in such way can play a meaningful role in helping patients to make informed decisions during the process of diagnostics and treatment.
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Quaglini S, Sacchi L, Lanzola G, Viani N. Personalization and Patient Involvement in Decision Support Systems: Current Trends. Yearb Med Inform 2017; 10:106-18. [PMID: 26293857 DOI: 10.15265/iy-2015-015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care. METHODS We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support. RESULTS We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness. CONCLUSIONS Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.
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Affiliation(s)
- S Quaglini
- Silvana Quaglini, Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Via Ferrata 5, 27100 Pavia, Italy, Tel: +39 0382 985058, Fax: +39 0382 985060, E-mail:
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Herrinton LJ, Altschuler A, McMullen CK, Bulkley JE, Hornbrook MC, Sun V, Wendel CS, Grant M, Baldwin CM, Demark-Wahnefried W, Temple LKF, Krouse RS. Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery. CA Cancer J Clin 2016; 66:387-97. [PMID: 26999757 PMCID: PMC5618707 DOI: 10.3322/caac.21345] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/13/2016] [Accepted: 02/09/2016] [Indexed: 12/14/2022] Open
Abstract
For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.
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Affiliation(s)
- Lisa J Herrinton
- Senior Research Scientist, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Andrea Altschuler
- Senior Consultant, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Carmit K McMullen
- Investigator, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Joanna E Bulkley
- Senior Research Associate, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Mark C Hornbrook
- Chief Scientist, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Virginia Sun
- Assistant Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA
| | - Christopher S Wendel
- Research Instructor, Arizona Center on Aging, University of Arizona College of Medicine, Tucson, AZ
| | - Marcia Grant
- Distinguished Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA
| | - Carol M Baldwin
- Professor Emerita and Southwest Borderlands Scholar, College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ
| | - Wendy Demark-Wahnefried
- Professor and Webb Endowed Chair of Nutrition Sciences, Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL
| | - Larissa K F Temple
- Colorectal Surgical Oncologist, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert S Krouse
- Staff General and Oncologic Surgeon, Professor of Surgery, Southern Arizona Veterans Affairs Health Care System and University of Arizona College of Medicine, Tucson, AZ
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Beaulac J, Sandre D. Critical review of bariatric surgery, medically supervised diets, and behavioural interventions for weight management in adults. Perspect Public Health 2016; 137:162-172. [PMID: 27354536 DOI: 10.1177/1757913916653425] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS Patient selection of weight management treatment option is often guided by a variety of factors. Currently, there is no comprehensive tool to facilitate informed decision-making for patients and clinicians. This article aims to synthesise evidence on the treatment effectiveness, health benefits, risks, and patient experiences of treatment options presently available at the Weight Management Clinic at The Ottawa Hospital (TOH), as a first step towards developing a decision aid. METHODS Narrative and systematic reviews published in English between 1999 and 2014 were included that focused on one or more of the following weight management treatments in adults aged 18 years and over: roux-en-y gastric bypass (RYGB), sleeve gastrectomy (SG), medically supervised meal replacement, and behavioural or lifestyle intervention. RESULTS Overall, bariatric surgeries have received the greatest research attention and have been associated not only with greater weight loss and health benefit but also with greater risks, complications, and financial cost. Dietary programmes demonstrated weight loss and health benefits to a lesser extent than with surgery but were associated with lower and shorter-term risks and complications. Behavioural and lifestyle interventions have been studied less yet have shown significant, albeit small, weight loss outcomes alone and in combination with dietary or surgical options; they also appear to be the lowest risk interventions. Patient experiences of weight management options are mixed and not well understood. CONCLUSION Further research is needed; however, this review identified some general trends related to weight loss outcomes, benefits, risks, and barriers for weight management options that have implications for shared treatment decision-making.
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Affiliation(s)
- Julie Beaulac
- Psychology Department, The Ottawa Hospital, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniella Sandre
- Psychology Department, The Ottawa Hospital, Ottawa, ON, Canada
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Abstract
BACKGROUND Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons. OBJECTIVE The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons. DESIGN This was a prospective cohort study. SETTINGS Patients and surgeons were enrolled from 3 colorectal surgery clinics. PATIENTS Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected. INTERVENTIONS Patients used a multilingual decision aid before meeting with the surgeon. MAIN OUTCOME MEASURES We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid. RESULTS Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients' knowledge scores improved by 39% (p < 0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid. LIMITATIONS The study included a small sample with no comparison group. CONCLUSIONS A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.
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Abstract
BACKGROUND In rectal cancer surgery, low anterior resection and abdominoperineal resection have equivocal impact on overall quality of life. A rectal cancer decision aid was developed to help patients weigh features of options and share their preference. OBJECTIVE The aim of this study was to evaluate the effect of a patient decision aid for mid to low rectal cancer surgery on the patients' choice and decision-making process. DESIGN A before-and-after study was conducted. Baseline data collection occurred after surgeon confirmation of eligibility at the first consultation. Patients used the patient decision aid at home (online and/or paper-based formats) and completed post questionnaires. SETTING This study was conducted at an academic hospital referral center. PATIENTS Adults who had rectal cancer at a maximum of 10 cm proximal to the anal verge and were amenable to surgical resection were considered. Those with preexisting stoma and those only receiving abdominoperineal resection for technical reasons were excluded from the study. INTERVENTION Patient with rectal cancer were provided with a decision aid. MAIN OUTCOME MEASURES The primary outcomes measured were decisional conflict, knowledge, and preference for a surgical option. RESULTS Of 136 patients newly diagnosed with rectal cancer over 13 months, 44 (32.4%) were eligible, 36 (81.9%) of the eligible patients consented to participate, and 32 (88.9%) patients completed the study. The mean age of participants was 61.9 ± 9.7 years and tumor location was on average 7.3 ± 2.1 cm above the anal verge. Patients had poor baseline knowledge (52.5%), and their knowledge improved by 37.5% (p < 0.0001) after they used the patient decision aid. Decisional conflict was reduced by 24.2% (p = 0.0001). At baseline, no patients preferred a permanent stoma, and after decision aid exposure, 2 patients (7.1%) preferred permanent stoma. Over 96% of participants would recommend the patient decision aid to others. LIMITATIONS This study was limited by the lack of control for potential confounders and potential response bias. CONCLUSIONS The patient decision aid reduced decisional conflict and improved patient knowledge. Participants would recommend it to other patients with rectal cancer.
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Levine MN, Julian JA, Bedard PL, Eisen A, Trudeau ME, Higgins B, Bordeleau L, Pritchard KI. Prospective Evaluation of the 21-Gene Recurrence Score Assay for Breast Cancer Decision-Making in Ontario. J Clin Oncol 2015; 34:1065-71. [PMID: 26598746 DOI: 10.1200/jco.2015.62.8503] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To evaluate the 21-gene recurrence score (RS) on decision-making in a population-based cohort. PATIENTS AND METHODS Patients with axillary node-negative or nodal micrometastases, estrogen receptor-positive, and human epidermal growth factor receptor 2-negative breast cancer being considered for chemotherapy were eligible. All cancer treatment centers in Ontario, Canada, participated. Oncologists made a preliminary recommendation for endocrine therapy with or without chemotherapy on the basis of Adjuvant! Online (AOL) risk estimation. Patients were asked for their preference regarding chemotherapy. After RSs were available, patients returned for final decision-making. Patient satisfaction was measured by using the decisional conflict scale. RESULTS Between January 2012 and July 2013, 1,000 patients were recruited. RSs were available for 979 patients. In 58% of patients, risk was categorized as low (RS, 0 to 18); in 33%, intermediate (RS, 19 to 30); and in 9%, high (RS, ≥ 31). Oncologists' recommendations pretest and post-test remained the same in 464 patients (48%), changed from unsure or chemotherapy to no chemotherapy in 365 (38%), and changed from unsure or no chemotherapy to chemotherapy in 143 (15%). After the test, oncologists recommended chemotherapy for 236 patients, 81% of whom received chemotherapy. Of 151 patients in whom risk was classified as intermediate by means of AOL, 41% were a low risk and 44% intermediate risk with RS. Of 298 patients at high risk with AOL, 16% had a high risk RS. None of 236 patients with grade I tumors had a high-risk RS. Mean total decisional conflict scale score significantly improved from pretest to post-test from 34 to 19 (P < .001). CONCLUSION The RS substantially influenced both oncologists' recommendations and patients' preferences for chemotherapy. The major effect was avoidance of chemotherapy when AOL indicated high or intermediate risk.
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Affiliation(s)
- Mark N Levine
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada.
| | - Jim A Julian
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Philippe L Bedard
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Andrea Eisen
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Maureen E Trudeau
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Brian Higgins
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Louise Bordeleau
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Kathleen I Pritchard
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
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Sier MF, van Gelder L, Ubbink DT, Bemelman WA, Oostenbroek RJ. Factors affecting timing of closure and non-reversal of temporary ileostomies. Int J Colorectal Dis 2015; 30:1185-92. [PMID: 26054385 PMCID: PMC4553149 DOI: 10.1007/s00384-015-2253-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although stoma closure is considered a simple surgical intervention, the interval between construction and reversal is often prolonged, and some ileostomies may never be reversed. We evaluated possible predictors for non-reversal and prolonged interval between construction and reversal. MATERIAL AND METHODS In a cohort study of ileostomy patients treated in a large teaching hospital, we collected data from the surgical complication and enterostomal therapists' registries between January 2001 and December 2011. Parameters responsible for morbidity, mortality, length of stay and time interval between construction and reversal were analysed. RESULTS Of 485 intentionally temporary ileostomies, 359 were reversed after a median of 5.6 months (IQR 3.8-8.9 months), while 126 (26%) remained permanent. End ileostomy and intra-abdominal abscess independently delayed reversal. Age, end ileostomy, higher body mass index and preoperative radiotherapy were independent factors for non-reversal. Median duration of hospitalisation for reversal was 7.0 days (5-13 days). Morbidity and mortality were 31 and 0.9%, respectively. In 20 patients (5.5%), re-ileostomy was necessary. CONCLUSIONS A substantial number of ileostomies that are intended to be temporary will never be reversed. If reversed, the interval between construction and reversal is longer than anticipated, while morbidity after reversal and duration of hospitalisation are considerable. Besides a temporary ileostomy, there are two other options: no diversion or a permanent colostomy. Shared decision-making is to be preferred in these situations.
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Affiliation(s)
- M. F. Sier
- />Department of Surgery, Albert Schweitzer Hospital, Location Dordwijk, Room: W0-051, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - L. van Gelder
- />Department of Surgery, Albert Schweitzer Hospital, Location Dordwijk, Room: W0-051, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - D. T. Ubbink
- />Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - W. A. Bemelman
- />Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - R. J. Oostenbroek
- />Department of Surgery, Albert Schweitzer Hospital, Location Dordwijk, Room: W0-051, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
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