Disclosing conflicts of interest in patient decision aids

Association of patient engagement strategies with utilisation and spending for musculoskeletal problems in the USA: a cross-sectional analysis of Medicare patients and physician practices

OBJECTIVE

Musculoskeletal problems like hip and knee osteoarthritis and low-back pain are preference sensitive conditions. Patient engagement strategies (PES), such as shared decision-making and motivational interviewing, can help align patients' preferences with treatment options and potentially reduce spending. We assess the association of physician practice-level adoption of PES with utilisation and spending.

DESIGN

Cross-sectional study in which patients were matched across low, moderate and high levels of PES via coarsened exact matching.

SETTING

Primary and secondary care in 2190 physician practices.

PARTICIPANTS

39 336 hip, 48 362 knee and 67 940 low-back patients who were Medicare beneficiaries were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total hip replacement (THR), total knee replacement (TKR), 1-2 level posterior lumbar fusion (LF), total annual spending, components of total annual spending.

RESULTS

Total annual spending for patients with musculoskeletal problems did not differ for practices with low versus moderate PES, low versus high PES or moderate versus high PES, but spending was significantly lower in some categories for practices with relatively higher PES adoption. For hospital-owned and health system-owned practices, the ORs of receiving LF were 0.632 (95% CI 0.396 to 1.009) for patients attributed to practices with high PES compared with patients attributed to practices with moderate PES. For independent practices, the odds of receiving THR were 1.403 (95% CI 1.035 to 1.902) for patients attributed to practices with moderate PES compared with patients attributed to practices with low PES.

CONCLUSIONS

Practice-level adoption of PES for patients with musculoskeletal problems was generally not associated with total spending. PES, however, may steer patients toward evidence-based treatments. Opportunities for overall spending reduction exist as indicated by the variation in the subcomponents of total spending by PES adoption.

Addressing Conflicts of Interest in Health and Medicine: Current Evidence and Implications for Patient Decision Aid Development

BACKGROUND

More stringent policies for addressing conflicts of interest have been implemented around the world in recent years. Considering the value of revisiting conflict of interest quality standards set by the International Patient Decision Aid Standards (IPDAS) Collaboration, we sought to review evidence relevant to 2 questions: 1) What are the effects of different strategies for managing conflicts of interest? and 2) What are patients' perspectives on conflicts of interest?

METHODS

We conducted a narrative review of English-language articles and abstracts from 2010 to 2019 that reported relevant quantitative or qualitative research.

RESULTS

Of 1743 articles and 118 abstracts identified, 41 articles and 2 abstracts were included. Most evidence on the effects of conflict of interest management strategies pertained only to subsequent compliance with the management strategy. This evidence highlighted substantial noncompliance with prevailing requirements. Evidence on patient perspectives on conflicts of interest offered several insights, including the existence of diverse views on the acceptability of conflicts of interest, the salience of conflict of interest type and monetary value to patients, and the possibility that conflict of interest disclosure could have unintended effects. We identified no published research on the effects of IPDAS Collaboration conflict of interest quality standards on patient decision making or outcomes.

LIMITATIONS

Because we did not conduct a systematic review, we may have missed some evidence relevant to our review questions. In addition, our team did not include patient partners.

CONCLUSIONS

The findings of this review have implications for the management of conflicts of interest not only in patient decision aid development but also in clinical practice guideline development, health and medical research reporting, and health care delivery.

Evidencia sobre conflictos de intereses en medicina

Introducción. La principal responsabilidad de los médicos es la de actuar en beneficio de los pacientes; sin embargo, existen situaciones en las cuales surgen intereses secundarios que pueden afectar este compromiso y generar conflictos de intereses.Objetivo. Analizar las revisiones sistemáticas y los metaanálisis actualmente disponibles en la literatura sobre el conflicto de intereses en medicina para sintetizar la información al respecto.Materiales y métodos. Se realizó una búsqueda en las bases de datos MEDLINE y LILACS mediante la siguiente estrategia de búsqueda: revisiones sistemáticas y metaanálisis sobre conflictos de intereses en medicina publicados en revistas científicas seriadas; no se aplicaron restricciones de idioma o año de publicación. Los estudios que cumplieron con los criterios de inclusión fueron agrupados según la actividad médica evaluada; además, de cada uno de ellos se extrajo la cantidad y el tipo de estudios y las conclusiones.Resultados. Se seleccionaron 29 publicaciones que se agruparon en estudios basados en artículos de investigación, en guías de práctica clínica, en la práctica clínica, y en publicaciones orientadas a los pacientes.Conclusiones. Los estudios originales incluidos en las revisiones sistemáticas y los metaanálisis analizados en el presente estudio no siempre reportan los conflictos de intereses; sin embargo, cuando estos se mencionan, hay una tendencia a presentar resultados que favorecen el medicamento o la tecnología del patrocinador.

Standards for UNiversal reporting of patient Decision Aid Evaluation studies: the development of SUNDAE Checklist

BACKGROUND

Patient decision aids (PDAs) are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. The International Patient Decision Aid Standards (IPDAS) Collaboration review papers and Cochrane systematic review of PDAs have found significant gaps in the reporting of evaluations of PDAs, including poor or limited reporting of PDA content, development methods and delivery. This study sought to develop and reach consensus on reporting guidelines to improve the quality of publications evaluating PDAs.

METHODS

An international workgroup, consisting of members from IPDAS Collaboration, followed established methods to develop reporting guidelines for PDA evaluation studies. This paper describes the results from three completed phases: (1) planning, (2) drafting and (3) consensus, which included a modified, two-stage, online international Delphi process. The work was conducted over 2 years with bimonthly conference calls and three in-person meetings. The workgroup used input from these phases to produce a final set of recommended items in the form of a checklist.

RESULTS

The SUNDAE Checklist (Standards for UNiversal reporting of patient Decision Aid Evaluations) includes 26 items recommended for studies reporting evaluations of PDAs. In the two-stage Delphi process, 117/143 (82%) experts from 14 countries completed round 1 and 96/117 (82%) completed round 2. Respondents reached a high level of consensus on the importance of the items and indicated strong willingness to use the items when reporting PDA studies.

CONCLUSION

The SUNDAE Checklist will help ensure that reports of PDA evaluation studies are understandable, transparent and of high quality. A separate Explanation and Elaboration publication provides additional details to support use of the checklist.

A systematic review of effectiveness of decision aids to assist older patients at the end of life

OBJECTIVE

To describe the range of decision aids (DAs) available to enable informed choice for older patients at the end of life and assess their effectiveness or acceptability.

METHODS

Search strategy covered PubMed, Scopus, Ovid MEDLINE, EMBASE, EBM Reviews, CINAHL and PsycInfo between 1995 and 2015. The quality criteria framework endorsed by the International Patient Decision Aids Standards (IPDAS) was used to assess usefulness.

RESULTS

Seventeen DA interventions for patients, their surrogates or health professionals were included. Half the DAs were designed for self-administration and few described use of facilitators for decision-making.

TREATMENT

options and associated harms and benefits, and patient preferences were most commonly included. Patient values, treatment goals, numeric disease-specific prognostic information and financial implications of decisions were generally not covered. DAs at the end of life are generally acceptable by users, and appear to increase knowledge and reduce decisional conflict but this effectiveness is mainly based on low-level evidence.

CONCLUSIONS

Continuing evaluation of DAs in routine practice to support advance care planning is worth exploring further. In particular, this would be useful for conditions such as cancer, or situations such as major surgery where prognostic data is known, or in dementia where concordance on primary goals of care between surrogates and the treating team can be improved.

PRACTICE IMPLICATIONS

Given the sensitivities of end-of-life, self-administered DAs are inappropriate in this context and genuine informed decision-making cannot happen while those gaps in the instruments remain.

Trustworthy patient decision aids: a qualitative analysis addressing the risk of competing interests

OBJECTIVE

Our aim in this study was to examine the competing interest policies and procedures of organisations who develop and maintain patient decision aids.

DESIGN

Descriptive and thematic analysis of data collected from a cross-sectional survey of patient decision aid developer's competing interest policies and disclosure forms.

RESULTS

We contacted 25 organisations likely to meet the inclusion criteria. 12 eligible organisations provided data. 11 organisations did not reply and 2 declined to participate. Most patient decision aid developers recognise the need to consider the issue of competing interests. Assessment processes vary widely and, for the most part, are insufficiently robust to minimise the risk of competing interests. Only half of the 12 organisations had competing interest policies. Some considered disclosure to be sufficient, while others imposed differing levels of exclusion.

CONCLUSIONS

Patient decision aid developers do not have a consistent approach to managing competing interests. Some have developed policies and procedures, while others pay no attention to the issue. As is the case for clinical practice guidelines, increasing attention will need to be given to how the competing interests of contributors of evidence-based publications may influence materials, especially if they are designed for patient use.

Features of Computer-Based Decision Aids: Systematic Review, Thematic Synthesis, and Meta-Analyses

Background

Patient information and education, such as decision aids, are gradually moving toward online, computer-based environments. Considerable research has been conducted to guide content and presentation of decision aids. However, given the relatively new shift to computer-based support, little attention has been given to how multimedia and interactivity can improve upon paper-based decision aids.

Objective

The first objective of this review was to summarize published literature into a proposed classification of features that have been integrated into computer-based decision aids. Building on this classification, the second objective was to assess whether integration of specific features was associated with higher-quality decision making.

Methods

Relevant studies were located by searching MEDLINE, Embase, CINAHL, and CENTRAL databases. The review identified studies that evaluated computer-based decision aids for adults faced with preference-sensitive medical decisions and reported quality of decision-making outcomes. A thematic synthesis was conducted to develop the classification of features. Subsequently, meta-analyses were conducted based on standardized mean differences (SMD) from randomized controlled trials (RCTs) that reported knowledge or decisional conflict. Further subgroup analyses compared pooled SMDs for decision aids that incorporated a specific feature to other computer-based decision aids that did not incorporate the feature, to assess whether specific features improved quality of decision making.

Results

Of 3541 unique publications, 58 studies met the target criteria and were included in the thematic synthesis. The synthesis identified six features: content control, tailoring, patient narratives, explicit values clarification, feedback, and social support. A subset of 26 RCTs from the thematic synthesis was used to conduct the meta-analyses. As expected, computer-based decision aids performed better than usual care or alternative aids; however, some features performed better than others. Integration of content control improved quality of decision making (SMD 0.59 vs 0.23 for knowledge; SMD 0.39 vs 0.29 for decisional conflict). In contrast, tailoring reduced quality of decision making (SMD 0.40 vs 0.71 for knowledge; SMD 0.25 vs 0.52 for decisional conflict). Similarly, patient narratives also reduced quality of decision making (SMD 0.43 vs 0.65 for knowledge; SMD 0.17 vs 0.46 for decisional conflict). Results were varied for different types of explicit values clarification, feedback, and social support.

Conclusions

Integration of media rich or interactive features into computer-based decision aids can improve quality of preference-sensitive decision making. However, this is an emerging field with limited evidence to guide use. The systematic review and thematic synthesis identified features that have been integrated into available computer-based decision aids, in an effort to facilitate reporting of these features and to promote integration of such features into decision aids. The meta-analyses and associated subgroup analyses provide preliminary evidence to support integration of specific features into future decision aids. Further research can focus on clarifying independent contributions of specific features through experimental designs and refining the designs of features to improve effectiveness.

Ten years of the International Patient Decision Aid Standards Collaboration: evolution of the core dimensions for assessing the quality of patient decision aids

In 2003, the International Patient Decision Aid Standards (IPDAS) Collaboration was established to enhance the quality and effectiveness of patient decision aids by establishing an evidence-informed framework for improving their content, development, implementation, and evaluation. Over this 10 year period, the Collaboration has established: a) the background document on 12 core dimensions to inform the original modified Delphi process to establish the IPDAS checklist (74 items); b) the valid and reliable IPDAS instrument (47 items); and c) the IPDAS qualifying (6 items), certifying (6 items + 4 items for screening), and quality criteria (28 items). The objective of this paper is to describe the evolution of the IPDAS Collaboration and discuss the standardized process used to update the background documents on the theoretical rationales, evidence and emerging issues underlying the 12 core dimensions for assessing the quality of patient decision aids.